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.

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· 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

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