Subjective: CC: dysuria and urinary frequency HPI: RG is a… Subjective:CC: dysuria and ur
Subjective: CC: dysuria and urinary frequency HPI: RG is a… Subjective:CC: dysuria and urinary frequencyHPI: 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.PMH: UTI 3 years agoPSHx: Hysterectomy at 25 yearsMedication: Tylenol 1000 mg PO every 6 hours for painFHx: Mother breast cancer (alive) Father hypertension (alive)Social: Single, no tobacco, works as a bartender, positive for ETOHAllergies: PCN and SulfaLMP: N/AReview of Symptoms:General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.Abdominal: Denies nausea and vomiting. No appetiteObjective:VS: Temp 100.9; BP: 136/80; RR 18; HT 6′.0″; WT 135lbsAbdominal: Bowel sounds present x 4. Palpation pain in both lower quadrants. CVA tendernessDiagnostics: Urine specimen collected, STD testingAssessment:UTISTDAnalyze 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. Health Science Science Nursing NURS 6512 Share QuestionEmailCopy link Comments (0)
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