Assignment 1: Assessing The Genitalia And Rectum
Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum
Assignment – Instructions
Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.
· Review and use the Episodic note case study for this week’s Assignment (see below). Complete with the additional information required for this Assignment
· Analyze the subjective portion of the note. List additional information that should be included in the documentation.
· Analyze the objective portion of the note. List additional information that should be included in the documentation.
· Is the assessment supported by the subjective and objective information? Why or why not?
· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
· Would you reject/accept the current diagnosis? Why or why not? Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
· Explain your reasoning using at least five different references from current evidence-based literature.
· APA 7
EPISODIC NOTE CASE STUDY
GENITALIA ASSESSMENT
Subjective:
CC: dysuria and urinary frequency
HPI: RG is a 30 year old female with increase urinary frequency and dysuria that began 3 days ago. Pain is intermittent and described a burning only in urination, but c/o flank pain since last night. Reports intermittent chills and fever. Used Tylenol for pain with no relief. She rates her pain 6/10 on urination. Reports a similar episode 3 years ago.
PMH: UTI 3 years ago
PSHx: Hysterectomy at 25 years
Medication: Tylenol 1000 mg PO every 6 hours for pain
FHx: Mother breast cancer ( alive) Father hypertension (alive)
Social: Single, no tobacco , works as a bartender, positive for ETOH
Allergies: PCN and Sulfa
LMP: N/A
Review of Symptoms:
General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
Abdominal: Denies nausea and vomiting. No appetite
Objective:
VS: Temp 100.9; BP: 136/80; RR 18; HT 6’.0”; WT 135lbs
Abdominal: Bowel sounds present x 4. Palpation pain in both lower quadrants. CVA tenderness
Diagnostics: Urine specimen collected, STD testing
Assessment:
UTI
STD
Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum
Assignment
–
Instructions
Using
evidence
–
based resources
from your sear
ch, answer the following questions and
support your answers using current evidence from the literature.
·
Review
and use
the Episodic note case study
for this week’s Assignment
(see
below)
.
C
omplete
with the
additional
infor
mation
required for this Assignment
·
Analyze the subjective portion of the note. List additional information that should be
included in the documentation.
·
Analyze the objective portion of t
he note. List additional information that should be
included in the documentation.
·
Is the assessment supported by the subjective and objective information? Why or why not?
·
Consider what physical exams and diagnostic tests would be appropriate to gather more
information a
bout the patient’s condition. How would the results be used to make a
diagnosis?
·
Would you reject/accept the current diagnosis? Why or why not?
Identify
at least
five
possible conditions that may be considered in a differential diagnosis for the patient.
·
Explain your reasoning using at least
five
different references from
current evidence
–
based
literature.
·
A
PA 7
EPISODIC NOTE CASE STUDY
GENITALIA ASSESSMENT
Subjective:
CC: dysuria and urinary frequency
HPI: RG is a 30 year old female with increase urinary frequency and dysuria that began 3 days ago. Pain
is intermittent and described a burning only in urination, but c/o flank pain since last night. Reports
intermittent chills and fever. Used Tylenol for
pain with no relief. She rates her pain 6/10 on urination.
Reports a similar episode 3 years ago.
PMH: UTI 3 years ago
PSHx: Hysterectomy at 25 years
Medication: Tylenol 1000 mg PO every 6 hours for pain
Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum
Assignment – Instructions
Using evidence-based resources from your search, answer the following questions and
support your answers using current evidence from the literature.
Review and use the Episodic note case study for this week’s Assignment (see below).
Complete with the additional information required for this Assignment
Analyze the subjective portion of the note. List additional information that should be
included in the documentation.
Analyze the objective portion of the note. List additional information that should be
included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?
Consider what physical exams and diagnostic tests would be appropriate to gather more
information about the patient’s condition. How would the results be used to make a
diagnosis?
Would you reject/accept the current diagnosis? Why or why not? Identify at least
five possible conditions that may be considered in a differential diagnosis for the patient.
Explain your reasoning using at least five different references from current evidence-based
literature.
APA 7
EPISODIC NOTE CASE STUDY
GENITALIA ASSESSMENT
Subjective:
CC: dysuria and urinary frequency
HPI: RG is a 30 year old female with increase urinary frequency and dysuria that began 3 days ago. Pain
is intermittent and described a burning only in urination, but c/o flank pain since last night. Reports
intermittent chills and fever. Used Tylenol for pain with no relief. She rates her pain 6/10 on urination.
Reports a similar episode 3 years ago.
PMH: UTI 3 years ago
PSHx: Hysterectomy at 25 years
Medication: Tylenol 1000 mg PO every 6 hours for pain
