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Subjective:CC: HPI: PMH:PSHx:Medication:FHx:Social:Allergies:LMP:Review of Symptoms:General: Abdominal: 

  • dysuria and urinary frequency
  • 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.
  •  UTI 3 years ago
  •  Hysterectomy at 25 years
  •  Tylenol 1000 mg PO every 6 hours for pain
  •  Mother breast cancer ( alive) Father hypertension (alive)
  •  Single, no tobacco , works as a bartender, positive for ETOH
  •  PCN and Sulfa
  •  N/A

  • Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
  • 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:

  • UTI
  • STD

 

 

Medications:

 

1 tablet Centrum Multivitamin Daily .

Protonix 20mg PO daily for GERD.

 

These findings, describe abnormal findings and as a provider develop an episodic note and you are allowed to make up vital signs and related body systems areas for the SOAP note.

  • 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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