Assessing the Genitalia and Rectum
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 = 37.3Â°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 adnexae
- no adnexal tenderness.
- No vaginal discharge is noted.
- The cervix appears normal.
Diagnostics: Urinalysis, STI testing, Papsmear
- 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.