In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions. Analyze each section of the SOAP and mention what’s missing and why do you need the missing to reach a diagnosis including labs, what’s appropriate for this case and 5 differentials including the primary diagnosis. You will not only mention the differentials you will also expand on the differentials. Everything needs literature justification APA, everything.
GENITALIA ASSESSMENT
CC: Increased frequency and pain with urination
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
Review of Systems:
- General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
- Abdominal: Denies nausea and vomiting. No appetite
Objective
VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.
Pelvic Exam:
- mild tenderness to palpation in the suprapubic area
- bimanual pelvic examination reveals a normal-sized uterus and adnexal.
- no adnexal tenderness.
- No vaginal discharge is noted.
- The cervix appears normal.
Diagnostics: Urinalysis, STI testing, Pap-smear
Assessment:
- UTI
- STI
Use as guide to answer assignment.
1.· Analyze the subjective portion of the note. List additional information that should be included in the documentation.
. 2 Analyze the objective portion of the note. List additional information that should be included in the documentation.
3 Is the assessment supported by the subjective and objective information? Why or why not?
4 What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
5 Would you reject or 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
This criterion is linked to a Learning Outcome Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria
This criterion is linked to a Learning Outcome Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation.
This criterion is linked to a Learning Outcome Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
