The 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?
• 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.

 

 

This should be written in a narrative format and not a SOAP note.

For this assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

Review the following Episodic note case study:

 

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

 

PLAN: This section is not required for the assignments in this course (NURS 6512) but

will be required for future course

Assessing the Genitalia and Rectum

Student’s Name

Institutional Affiliations

Assessing the Genitalia and Rectum

Collecting a comprehensive medical history is a crucial step towards making an accurate diagnosis. The subjective data gives information concerning how a patient is feeling and the number of days that symptoms have lasted. Besides, it is by performing physical exams that the healthcare provider is able to identify pathological issues that are causing a patient’s symptoms (Ball et al., 2016). The purpose of this assignment is to review a patient’s subjective, objective, and assessment sections of the SOAP note and provide details regarding what is missing including the differential diagnoses aligned with her symptoms.

Subjective Portion

The subjective portion of the needs to include additional information related to the review of systems. Additional information to be included in this section should be that which is related to the HEENT (head, eyes, ears, nose, and throat), neck, respiratory, cardiovascular, genitourinary, musculoskeletal, and psychiatric assessment results as reported by the patient. It is also important to gather additional data regarding whether the current symptoms were triggered by some foods consumed recently, including exacerbating and relieving factors (Dains et al., 2016).

Objective Portion

The objective portion of the note is not comprehensive enough to enable the healthcare provider to make a decision regarding the patient’s diagnosis. The information provided in relation to vital signs, abdominal assessment, and diagnostics alone is quite limited. Additional information that should be added should include physical assessment results of the musculoskeletal, skin, respiratory, cardiovascular, endocrine, and genitourinary systems. Assessment results related to the head, eyes, ears, nose, and throat (HEENT) should also be included (Dains et al., 2016).

Appropriateness of the Assessment

The assessment is supported by the objective and subjective portions of the note. This is so despite the fact that the objective assessment was not that comprehensive. Urinary tract infections and sexually transmitted diseases can cause dysuria and increased urination frequency in the affected patients (American Academy of Family Physicians, 2016). From the subjective data, the patient has reported that she has dysuria, urination frequency, intermittent pain, burning sensation during urination, as well as intermitted fever and chills. Objective data that might confirm the presence of a sexually transmitted disease and/or a urinary tract infection include CVA tenderness, bowel sounds, and pain in both lower quadrants (Ball et al., 2016). Such positive findings are indicative of genitourinary infections.

Diagnostic Tests

It is essential to conduct diagnostic tests to rule it the presence of other diseases and to confirm the presence of urinary tract infection or a sexually transmitted disease. The diagnostic tests that should be conducted include urinalysis, urine culture, and culture of the vaginal swab (Herath et al., 2021). These tests will help to establish the actual cause of the patient’s symptoms.

Rejecting/Accepting the Diagnosis

I would accept the given diagnosis based on the patient’s objective and subjective data. Dysuria and urination frequency are usually positive symptoms in patients with urinary tract infections and sexually transmitted diseases. Additional findings that support these two diagnoses are intermittent pain, burning sensation during urination, intermitted fever and chills, CVA tenderness, bowel sounds, and pain in both lower quadrants (American Academy of Family Physicians, 2016; Herath et al., 2021).

Differential Diagnoses

Urinary tract infection (Primary diagnosis): This is confirmed by the presence of dysuria and urinary frequency without vaginal discharge. Other findings that support this diagnosis are intermittent pain, burning sensation during urination, intermitted fever and chills, CVA tenderness, bowel sounds, and pain in both lower quadrants (American Academy of Family Physicians, 2016; Herath et al., 2021)

Sexually transmitted disease: Diseases symptoms normally resemble those of urinary tract infection described above. However, affected females normally have a vaginal discharge which is absent in the patient (American Academy of Family Physicians, 2016).

Type 2 diabetes: Urination frequency is a primary symptom in individuals with type 2 diabetes. However, dysuria, pain, and burning sensation during urination are normally absent (Xu et al., 2017).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

American Academy of Family Physicians. (2016). Dysuria: evaluation and differential diagnosis in adults. https://www.aafp.org/afp/2015/1101/p778.html

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2016). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Herath, S., Balendran, T., Herath, A., Iddawela, D., & Wickramasinghe, S. (2021). Comparison of diagnostic methods and analysis of socio-demographic factors associated with Trichomonas vaginalis infection in Sri Lanka. PLoS ONE, 16(10): e0258556. https://doi.org/10.1371/journal.pone.0258556

Xu, D., Cheng, R., Ma, A., Zhao, M., & Wang, K. (2017). Toileting behaviors and overactive bladder in patients with type 2 diabetes: a cross-sectional study in China. BMC Urology, 17(1), 42. https://doi.org/10.1186/s12894-017-0234-2