Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
- Based on the Episodic note case study:
- Review this week’s 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 Assignment.
- Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
- Consider what history would be necessary to collect from the patient in the case study.
- 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?
- Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
The Lab Assignment
Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.
- 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?
- Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
- 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.
GENITALIA ASSESSMENT (Review the requirements in this week’s course resources. You can write this assignment in narrative format.
- 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
- 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