Reproductive System
Description
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Please analyze the following case study: and Make an Episodic SOAP note.
GENITALIA ASSESSMENT
Subjective:
- CC: dysuria and urinary frequency
HPI: T.S. is a 32-year-old woman who reports that for the past two days, she has dysuria, frequency, and urgency. Has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months.
Medical History:
None
Surgical History:
- Tonsillectomy in 2001
- Appendectomy in 2020
- PMH: UTI 3 years ago
- PSHx: Hysterectomy at 25 years
- Medication: Tylenol 1000 mg PO every 6 hours for pain
- FHx: Mother breast cancer ( alive) Father hypertension (alive)
- Social: Single, no tobacco , works as a bartender, positive for ETOH
- Allergies: PCN and Sulfa
- LMP: N/A
Review of Symptoms:
- General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
- Abdominal: 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.
Support your case study using 5 APA citation reference with nursing background within last five years.
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- Consider what history would be necessary to collect from the patient in the case study.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
- Would you reject/accept the current diagnosis? Why or why not?
- Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
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