Assignment 1: Lab Assignment: 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.

 

 

·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

 

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