CC: dysuria and urinary frequency
HPI: RG is a 30 year old female with increase urinary frequency anddysuria that began 3 days ago. Pain is intermittent and described a burningonly in urination, but c/o flank pain since last night. Reports intermittentchills and fever. Used Tylenol for pain with no relief. She rates her pain 6/10on urination. Reports a similar episode 3 years ago.
PMH: UTI3 years ago
PSHx: Hysterectomyat 25 years
Medication: Tylenol 1000 mg PO every 6 hours for pain
FHx: Motherbreast cancer ( alive) Father hypertension (alive)
Social: Single, no tobacco , works as a bartender, positive for ETOH
Allergies: PCN and Sulfa
Review of Symptoms:
General: Denies weight change, positive for sleeping difficulty because ethe 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
Using evidence-based resources from your search,answer the following questions and support your answers using current evidencefrom 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.
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