Posted: February 3rd, 2023
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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, I mean everything
CC: Increased frequency and pain with urination
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.
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
VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.
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
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
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 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 differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
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