Analyze the subjective portion of the note

Reference no: EM133502688

Lab Homework: Assessing the Genitalia and Rectum

A. Review the Episodic note case study your instructor provides you for the Homework. See the "Course Announcements" section of the classroom for your Episodic note case study.

B. Based on the Episodic note case study:

Question 1. Review this Learning Resources and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Homework.

Question 2. Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.

Question 3. Consider what history would be necessary to collect from the patient in the case study.

Question 4. 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?

Question 5. Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

Homework is a Case Study Analysis:

Genitourinary Assessment

CC: Increased frequency and pain with urination

HPI:

T.S. is a 32-year-old woman who reports that for the past two days, she has dysuria, frequency, and urgency. Has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has had a new partner for the past 3 months.

I. Medical History:

None

II. Surgical History:

1. Tonsillectomy in 2001
2. Appendectomy in 2020

III. Review of Systems:

1. General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
2. Abdominal: Denies nausea and vomiting. No appetite

IV. Objective

VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.

V. Pelvic Exam:

1. mild tenderness to palpation in the suprapubic area
2. bimanual pelvic examination reveals a normal-sized uterus and adnexae
3. no adnexal tenderness.
4. No vaginal discharge is noted.
5. The cervix appears normal.
6. Diagnostics: Urinalysis, STI testing, Papsmear

VI. Assessment:

• UTI
• STI

VII. PLAN: This section is not required for the homeworks in this course (NURS 6512) but will be required for future courses.

Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from literature.

Question 1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.

Question 2. Analyze the objective portion of the note. List additional information that should be included in the documentation.

Question 3. Is the assessment supported by the subjective and objective information? Why or why not?

Question 4. Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?

Question 5. Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

Question 6. John Hopkins and Mayo Clinic are not Scholarly Resources. Use more than one reference source to support your differential diagnosis.

Reference no: EM133502688

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