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

Question

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.

Answer 1

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