Review the following Episodic note case study:
Genitourinary Assessment Case Study
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 a new partner for the past 3 months.
Medical History:
None
Surgical History:
- Tonsillectomy in 2001
- Appendectomy in 2020
Review of Systems: - General: Denies weight change, positive for sleeping difficulty because of the flank pain. Feels warm.
- Abdominal: Denies nausea and vomiting. No appetite
Objective
VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.
Pelvic Exam: - mild tenderness to palpation in the suprapubic area
- bimanual pelvic examination reveals normal-sized uterus and adnexa
- no adnexal tenderness
- No vaginal discharge is noted
- The cervix appears normal
Diagnostics: Urinalysis, STI testing, Pap smear
Assessment: - UTI
- STI
- 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 (Please complete in a narrative format so you can explain your thoughts fully. Do not add information in an episodic note format)
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 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.