GENITALIA ASSESSMENT
Subjective:
· CC: dysuria and urinary frequency
· HPI: 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 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
The Assignment
Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.
· 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.
Sample Paper
Subjective:
dysuria
urinary frequency
intermittent pain 6/10 (burning and flankpain., intermittent fever and chills,
PMH: UTI 3 years ago
sleeping difficulty due to flank pain
Feels warm.
Objective:
VS: Temp 100.9; BP: 136/80; HT 6′.0″; WT 135lbs
CVA tenderness
Assessment:
- UTI
Planning:
-encourage to increase oral fluid intake.
-Encourage to urinate post sexual activity.
– Educate and encourage to do proper perineal hygiene.
Recommend to start antibiotic.
-Recommend to do urine CS.
-Recommend to do septic work up.
-Recommend to do renal function test.
-Continue to give tynelol for fever.
1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Characteristics of urine.
vaginal discharge
pain during intercourse
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
blood sugar
The result of the laboratories should also be included.
CBC, CRP, procalcitonin and urine CS.
KUB ultrasound .
3. Is the assessment supported by the subjective and objective information? Why or why not?
Yes. The subjective and objective assessment is enough to make a diagnosis of UTI.
4. Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
Yes, the results of the test will confirm the diagnosis of the patient.
5. Would you reject/accept the current diagnosis? Why or why not? I will accept because the available data indicates that the patient is having UTI.
6. 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.
bladder cancer
STD
vaginitis
Planning:
-encourage to increase oral fluid intake. -to promote diuresis and elimination of pathogen in urine.
-Encourage to urinate post sexual activity. – to remove pathogen out of the urinary tract that is possibly enter due to sexual intercourse.
– Educate and encourage to do proper perineal hygiene. – to remove pathogen.
Recommend to start antibiotic. – to kill the bacterial infection.
-Recommend to do urine CS – to detect the microorganisms and its sensitivity to antibiotic which will guide the management of the patient.
-Recommend to do septic work up.- to rule out the possibility of systemic infection.
-Recommend to do renal function test – to check the kidney if its affected with the UTI.
-Continue to give tynelol for fever.
1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Characteristics of urine.
vaginal discharge
pain during intercourse
– these are the important information that the nurse needs to ask the patient because it can guide to the correct diagnosis of the patient.
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
blood sugar – just to rule out diabetes as a reason why there is urinary frequency, and high blood sugar can predispose the patient to have recurrent UTI.
The result of the laboratories should also be included to for the correct diagnosis.
CBC, CRP, procalcitonin and urine CS – should be done to check for signs of infection and presence of microorganisms in the urine.
KUB ultrasound should also be done to check the status of the urinary tract and to check for any mass.
3. Is the assessment supported by the subjective and objective information? Why or why not?
Yes. The subjective and objective assessment is enough to make a diagnosis of UTI. Subjective data includes patient’s complaints and data gathered to the patient is enough. Additionally, Objective data which the data gathered by the healthcare provider or examiner give additional proof to have a correct diagnosis. With regards to STD, which has same complaints as what the patient is experiencing is enough to tell that the patient is possibly has it.
4. Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
Yes, the results of the test will confirm the diagnosis of the patient. Presence of large amount of bacteria in the urine indicates UTI.
5. Would you reject/accept the current diagnosis? Why or why not? Yes because the available data indicates that the patient is having UTI. These assessments are increased urinary frequency, dysuria, intermittent fever, flank pain and verbalization of “same symptoms 3 years ago” when she was diagnosed with UTI.
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.
bladder cancer – this can also cause urine frequency and dysuria due to the increase bladder pressure and decrease capacity of the bladder to hold urine.
STD – this is also possible because the patient is having dysuria, fever. Although there is no data regarding pain during intercourse and vaginal discharge in the assessment which if taken can really help with the diagnosis of STD.
vaginitis – this can also cause both complaints of the patient and other similar assessment data but there is no data regarding vaginal discharge so there is a possibility that this is not the case.
