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Genitourinary 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: ï‚· Tonsillectomy in 2001 ï‚· Appendectomy in 2020 Review of Systems: ï‚· General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm. ï‚· 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: ï‚· mild tenderness to palpation in the suprapubic area ï‚· bimanual pelvic examination reveals a normal-sized uterus and adnexae ï‚· no adnexal tenderness. ï‚· No vaginal discharge is noted. ï‚· The cervix appears normal. Diagnostics: Urinalysis, STI testing, Papsmear Assessment: ï‚· UTI ï‚· STI This week we will cover Special Examinations-Breast, Genital, Prostate and Rectal Systems. You will analyze the SOAP note provided in the assignment above. List additional information that should be included in documentation. Analyze the objective portion of the SOAP note, List additional information that should be included in documentation. Would you reject or accept the current diagnosis? Why or Why not? Explain your reasoning using at least 3 different references from current evidence-based literature. Evidence Based Literature is usually from Peer Reviewed Journals. In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. Before you begin your assignment review Special Examinations, understand what is included in physical examination, it will help you evaluate SOAP note. 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. Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature. ï‚· Analyze the subjective portion of the note. List additional information that should be included in the documentation. ï‚· Analyze the objective portion of the note. List additional information that should be included in the documentation. ï‚· Is the assessment supported by the subjective and objective information? Why or why not? ï‚· Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis? ï‚· 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… Please include references
SCIENCE
HEALTH SCIENCE
NURSING
NURS 6512