Case study:
CC: dysuria and urinary frequency
HPI: RG is a 30-year old female with increased 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 hypertensioon (alive)
Social: Single, no tobacco, works as a bartender, positive for ETOH
Allergies: PCN and Sulfa
LMP: N/A
Assessment:
- UTI
- STD
Assignment:
- Analyze the subjective porition of the note. List additional information that should be included in the documentation.
- Analyze the objective portion of the scenerio. List additional information that should be included in the documentation
- Is the assessment supported by the subjective and objective informationo? 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 reasooning using at least three different references
from current evidence-based literature
Sample Solution