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TheEPISODICNOTECASESTUDY.docx

TheEPISODICNOTECASESTUDY.docx

This week’s focus is on the Assessing the Genitalia and Rectum. 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.

Assignment: Assessing the Genitalia and Rectum

Review the following Episodic note case study:

 TO PREPARE

· 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.

The Lab Assignment (Please complete in a narrative format so you can explain your thoughts fully. Do not add information in an episodic note format)

THE QUESTION

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?

· What diagnostic test would 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.

Genitourinary Assessment Case Study

Episodic Focus Note

CC (Chief Complaint): Increased frequency and pain with urination

HPI (History of Present Illness): 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 DATA

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 suprapubic area

· bimanual pelvic examination reveals normal-sized uterus and adnexa

· 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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