Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.

· Based on the Episodic note case study:

· Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.

· Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.

· 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

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 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 (Review the requirements in this week’s course resources. You can write this assignment in narrative format.

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

· FHx: Mother breast cancer ( alive) Father hypertension (alive)

· Social: Single, no tobacco , works as a bartender, positive for ETOH

· Allergies: PCN and Sulfa

· LMP: N/A

Review of Symptoms:

· General: Denies weight change, positive for sleeping difficulty because e 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 x 4. Palpation pain in both lower quadrants. CVA tenderness

· Diagnostics: Urine specimen collected, STD testing

Assessment: