Using evidence-based resources from your search (at least 3 references), answer the following questions and support your answers using current evidence from the literature. This should be a narrative paper.
· 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.
· 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
· 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
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