In this Lab 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. Analyze each section of the SOAP and mention what’s missing and why do you need the missing to reach a diagnosis including labs, what’s appropriate for this case and 5 differentials including the primary diagnosis. You will not only mention the differentials you will also expand on the differentials. Everything needs literature justification APA, everything.
GENITALIA ASSESSMENT
CC: Increased frequency and pain with urination
HPI:
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
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 a normal-sized uterus and adnexal.
- no adnexal tenderness.
- No vaginal discharge is noted.
- The cervix appears normal.
Diagnostics: Urinalysis, STI testing, Pap-smear
Assessment:
- UTI
- STI
Use as guide to answer assignment.
1.· Analyze the subjective portion of the note. List additional information that should be included in the documentation.
. 2 Analyze the objective portion of the note. List additional information that should be included in the documentation.
3 Is the assessment supported by the subjective and objective information? Why or why not?
4 What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
5 Would you reject or 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
This criterion is linked to a Learning Outcome Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria
This criterion is linked to a Learning Outcome Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation.
This criterion is linked to a Learning Outcome Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
Expert Solution Preview
Introduction:
In this lab assignment, we will analyze an episodic case study of a patient who complains of increased frequency and pain with urination. We will evaluate the medical history, surgical history, review of systems, subjective and objective portions of the note, and diagnostic tests performed. We will also formulate a differential diagnosis with several possible conditions and expand on each. The answers provided will be supported with evidence-based literature and follow the correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
The subjective portion of the note provides information on the patient’s history of dysuria, frequency, and urgency for the past two days. Additional information that should be included includes the duration and severity of symptoms, the exact location of pain or discomfort, any recent sexual activity, and any previous UTI episodes. The patient’s menstrual history and contraceptive use should also be documented.
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
The objective portion of the note provides information on vital signs, pelvic exam, and diagnostics. Additional information that should be included in the documentation includes the patient’s general appearance, skin color, respiratory rate and effort, breath sounds, heart rate, rhythm, and intensity; abdominal exam findings; and STI testing results. In the pelvic exam, any mass, adnexal tenderness, and cervical motion tenderness should be noted.
3. Is the assessment supported by the subjective and objective information? Why or why not?
Yes, the assessment of UTI and STI is supported by the subjective and objective information provided in the note. The patient complains of dysuria, frequency, and urgency, and pelvic exam findings reveal mild tenderness to palpation in the suprapubic area. Diagnostic tests such as urinalysis and STI testing confirm the diagnosis.
4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
Diagnostic tests appropriate for this case include urinalysis, urine culture, STI testing, and pelvic ultrasound. Urinalysis and urine culture will confirm the presence of bacteria in the urine, which will diagnose UTI. STI testing will help diagnose any sexually transmitted infections, which can be the cause of dysuria, frequency, and urgency. A pelvic ultrasound will help diagnose any abnormalities in pelvic organs or structures that may be causing the symptoms.
5. Would you reject or 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.
I would accept the current diagnosis of UTI and STI based on the subjective and objective information provided in the note and diagnostic tests. Three possible conditions that may be considered as differential diagnoses for this patient include interstitial cystitis, vulvovaginal candidiasis, and pyelonephritis. Interstitial cystitis is a chronic bladder condition with symptoms similar to UTI, and vulvovaginal candidiasis is a fungal infection that may cause dysuria and vulvovaginal itching. Pyelonephritis is a severe UTI that may cause fever, flank pain, and nausea. (Litwin, Saigal, & Yano, 2012; Sobel & Nyirjesy, 2013; Gonzales, Barrett, & Gupta, 2015)
