USE THIS Week_5_Episodic_Focused_SOAP_Note_Template. UPLOADED TO DO THIS ASSIGNMENT AND SAMPLE UPLOADED Post_Week_8.docx.pdf TO SEE EXAMPLE.
copy and paste in google search AND DOWNLOAD to see TEXTBOOK ( http://library.lol/main/e73fad1b3e0273be8d40b51e14356523 ) = READ Chapter 19, “Female Genitalia” In this chapter, the authors explain how to conduct an examination of female genitalia. The chapter also describes the form and function of female genitalia.
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.
1- 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.
2- Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
3- 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?
4-Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
When “analyzing” this does not mean to write the rest of a SOAP artificially created by you, it means to look at the case and to write what else do you need on the subjective to make my diagnosis and to justify your writing with PEER REVIEW LITERATURE (JOURNALS) not some internet site. Look at the objective, what’s the physical exam needed based on the case given and explain why do you need this exam. Same applies for the diagnosis and differential. This is the request for this week, this is by the rubric and deductions will be done by the rubric
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 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 a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
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 had 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 had 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 adnexa
no adnexal tenderness.
No vaginal discharge is noted.
The cervix appears normal.
Diagnostics: Urinalysis, STI testing, Pap smear
Assessment:
UTI
STI
.