Case Study

Based on the Episodic note case study:

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.

• 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 (from the 5) 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

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 e 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 supra-pubic area

bimanual pelvic examination reveals a normal-sized uterus and adnexal

no adnexal tenderness.

No vaginal discharge is noted.

The cervix appears normal.

Diagnostics: Urinalysis, STI testing, Pap-smear

Assessment:

UTI

STI

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