RG is a 30-year-old female with increase urinary frequency and dysuria

Urinary frequency and dysuria

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
• 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.