\u2022\tReview the Episodic note case study your instructor provides you for this week\u2019s Assignment. Please see the \u201cCourse Announcements\u201d section of the classroom for your Episodic note case study.
\n\u2022\tBased on the Episodic note case study:
\no\tReview this week\u2019s 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.
\no\tSearch the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
\no\tConsider what history would be necessary to collect from the patient in the case study.
\no\tConsider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\u2019s condition. How would the results be used to make a diagnosis?
\no\tIdentify at least five possible conditions that may be considered in a differential diagnosis for the patient.
\nThe Lab Assignment
\nUsing evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.
\n\u2022\tAnalyze the subjective portion of the note. List additional information that should be included in the documentation.
\n\u2022\tAnalyze the objective portion of the note. List additional information that should be included in the documentation.
\n\u2022\tIs the assessment supported by the subjective and objective information? Why or why not?
\n\u2022\tWould diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
\n\u2022\tWould 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.<\/p>\n
GENITALIA ASSESSMENT (Review the requirements in this week’s course resources. You can write this assignment in narrative format.
\nSubjective:
\n\u2022\tCC: dysuria and urinary frequency
\n\u2022\tHPI: 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.
\n\u2022\tPMH: UTI 3 years ago
\n\u2022\tPSHx: Hysterectomy at 25 years
\n\u2022\tMedication: Tylenol 1000 mg PO every 6 hours for pain
\n\u2022\tFHx: Mother breast cancer ( alive) Father hypertension (alive)
\n\u2022\tSocial: Single, no tobacco , works as a bartender, positive for ETOH
\n\u2022\tAllergies: PCN and Sulfa
\n\u2022\tLMP: N\/A
\nReview of Symptoms:
\n\u2022\tGeneral: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
\n\u2022\tAbdominal: Denies nausea and vomiting. No appetite
\nObjective:
\n\u2022\tVS: Temp 100.9; BP: 136\/80; RR 18; HT 6\u2019.0\u201d; WT 135lbs
\n\u2022\tAbdominal: Bowel sounds present x 4. Palpation pain in both lower quadrants. CVA tenderness
\n\u2022\tDiagnostics: Urine specimen collected, STD testing
\nAssessment:
\n\u2022\tUTI
\n\u2022\tSTD<\/p>\n
—<\/p>\n
\u2022 Review the Episodic note case study provided by your instructor for this week’s Assignment. Please find your Episodic note case study in the “Course Announcements” area of the classroom.
\n\u2022 Based on the case study of the Episodic note:<\/p>\n
o Go over this week’s Learning Resources and think about the insights they offer concerning the case study. To complete your Lab Assignment, refer to Chapter 3 of the Sullivan reference.<\/p>\n
o Look for evidence-based materials in the Walden library or on the Internet to back up your responses to the questions supplied.<\/p>\n
o Consider what information would need to be gathered from the patient in the case study.<\/p>\n
o Consider what physical exams and diagnostic testing might be necessary to learn more about the patient’s condition. What would you do?<\/p>\n","protected":false},"excerpt":{"rendered":"
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