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/AReview of Symptoms:• General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.• Abdominal: Denies nausea and vomiting. No appetiteObjective:• 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 testingAssessment:• UTI• STD 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.
