To Prepare

• Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
• Based on the Episodic note case study:
  • Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.
  • Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
  • 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?
  • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

The Lab 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

Week 10

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

 

Reproductive Assessment

Name

Institution

Date

Reproductive Assessment

Clinicians need to document patients’ details accurately to ensure that they make an accurate diagnosis while at the same time ensuring that they design a patient-centered treatment plan. According to Sullivan (2012), a patient’s medical information is a memory aid to the health practitioners. It would be vital for clinicians to rely on both objective and subjective details to make informed medical decisions.  This paper will look at the patient study of a 30-year old female who presents with an increase in urinary frequency and dysuria that began three days ago.

Additional Subjective Information

Sexual history:

Whether she has had sexual intercourse for the last two weeks

Associated symptoms like itching and tenderness around the genitalia

History of previous illness- Questions concerning the previous diagnosis three years ago, the medications used, and the period the symptoms lasted.

Description of urine:

Color- is it is yellow, bloody, clear, or cloudy

Urgency of urination

Additional Objective information

Pelvic examination- A pelvic examination should be carried out to rule out other symptoms like pelvic bleeding, sexually transmitted infections, and abdominal pain.

Physical examination- should be palpated for tenderness and adnexal mass

Assessment

Based on the case study, the patient assessment done was for urinary tract infection and sexually transmitted disease. The patient has been having dysuria and urinary frequency. Nursing literature indicates that in women, urinary tract infections are the most causes of dysuria. Frequent urination is caused by infection, injury, or irritation of the bladder.  It is also important to note that the patient has a history of urinary tract infection three years ago.  The patient’s subjective and objective information support the assessment.

Diagnostics Studies   

Diagnostic studies ensure that the clinician develops differential diagnoses while allowing him/her narrow down on the most accurate diagnosis. Clinicians that rely on diagnostic studies can design correct and patient-centered treatment plans. Diagnostic studies that should be done for the diagnosis of urinary tract infections include a urinalysis and a urine culture (Bazzaz et al., 2021). Other tests that can be used include blood tests and nucleic amplification tests which will be used to rule out sexually transmitted diseases. I would therefore accept the current diagnosis of urinary tract infection and sexually transmitted diseases based on the patient’s clinical manifestations and history of the disease.

Differential Diagnoses

Urinary tract infection

Urinary tract infection is the most common bacterial infection among women. The infections are usually caused by bacteria and other microorganisms such as fungi and viruses (Bazzaz et al., 2021).  Urinary tract infections either appear as complicated or uncomplicated. Uncomplicated UTIs mainly occur without functional abnormalities in the urinary tract. Complicated urinary tract infections usually occur with abnormal urinary tracts which makes them more vulnerable to infections. The most common bacteria that cause urinary tract infections is Escherichia coli. The uropathogenic bacteria also produce other substances like colony necrotizing factors, toxins, and hemolysin. The above factors disrupt the epithelial integrity and at the same time allow bacterial invasion. Risk factors that increase the women’s vulnerability include age, sexual activity, female anatomy, and various types of birth control. Other factors include urinary tract abnormalities, a suppressed immune system, catheter use, and a recent urinary procedure.

Cystisis

Cystitis refers to an infection of the lower urinary tract. The condition is usually caused by a bacterial infection of the urinary bladder. Escherichia coli is the most common etiologic agent that causes UTIs in 75 to 95 percent of the cases (Li & Leslie, 2021). Other agents include Enterobacteriaceae family such as staphylococcus saprophyticus. The condition usually happens because of colonization of periurethral mucosa by bacteria from either vaginal or fecal flora. Symptoms include dysuria, urinary frequency, urgency, hematuria, pain, and tenderness.

Urethritis

Urethritis refers to the inflammation of the urethra, a tube that carries urine from the bladder out of the body. It is either a bacterial or a viral infection that causes swelling and irritation of the urethra. It is caused by a sexually transmitted infection (Hakenberg et al., 2017). Symptoms include frequent urination, painful urination, and discharge from the urethra.

 

 

Chlamydia

Chlamydia is the most prevalent bacterial infection across the US. Nursing literature indicates that a majority of the cases are usually asymptomatic. However, the condition can present with dysuria (acute urethra syndrome) which resembles a urinary tract infection. If left untreated individuals suffering from the condition can suffer complications such as pelvic inflammatory disease, ectopic pregnancy, and infertility.

Acute pyelonephritis

Acute pyelonephritis refers to a bacterial infection that causes inflammation of the kidneys which occurs as a complication of the urinary tract infection. It usually spreads from the bladder to the kidneys. The signs and symptoms include cloudy, bloody, dark, or foul-smelling urine, pain in the back, fever, chills, frequent and painful urination, nausea, and vomiting.

Based on the patient’s history of disease and clinical manifestation, it would be necessary for the clinician to conduct a detailed assessment of the female reproductive system. Besides the patient’s signs and symptoms, it would be vital to look at the patient’s medical, social and reproductive history. The above information would ensure that an accurate diagnosis is made. Based on the case study provided, there is a need to combine both subjective and objective information to make a meaningful clinical decision.

References

Bazzaz, B. S. F., Fork, S. D., Ahmadi, R., & Khameneh, B. (2021). Deep insights into urinary tract infections and effective natural remedies. African Journal of Urology, 27(1), 1-13.

Hakenberg, O. W., Harke, N., & Wagenlehner, F. (2017). Urethritis in men and women. European Urology Supplements, 16(4), 144-148.

Li, R., & Leslie, S. W. (2021). Cystitis. StatPearls [Internet].

Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
Gnann Jr, John W., and Richard J. Whitley. “Genital herpes.” New England Journal of Medicine 375, no. 7 (2016): 666-674.