Case study:
CC: dysuria and urinary frequency
HPI: RG is a 30-year old female with increased 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 hypertensioon (alive)
Social: Single, no tobacco, works as a bartender, positive for ETOH
Allergies: PCN and Sulfa
LMP: N/A
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:
* VS: Temp 100.9; BP: 136/80; RR 18: HT 6’0″; WT 135lbs
* Abdominal: Bowel sounds present x4. Palpation pain in both lower quadrants. CVA tenderness
* Diagnostics: Urine specimen collected, STD testing
Assessment:
* UTI
* STD
Assignment:
– Analyze the subjective porition of the note. List additional information that should be included in the documentation.
– Analyze the objective portion of the scenerio. List additional information that should be included in the documentation
– Is the assessment supported by the subjective and objective informationo? 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 reasooning using at least three different references
from current evidence-based literature
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
