Assignment
• Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
• Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 codes for the diagnosis. What was your primary diagnosis and why?
• Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
• Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

Case study
Patient ID -10132011
Visit information-JB is a 13 year old female presents to pediatric clinic for UTI. Mom reports she finished her antibiotics one month ago when previously diagnosed with a UTI but JB is having symptoms of UTI again. Mom reports 5 times in one year. Patient reports cloudy urine and an odor coming from her vaginal area. Mom reports the odor is terrible and sometimes can be smelled through her clothes. She has been given Bactrim and Macrobid without any positive results. Her mother reports she get better for a little while and then comes right back. Child reports no discharge, or dysuria, or frequent urination. Only and odor. Menstrual cycles and erratic and sometimes comes more than once a month. JB claims she is a virgin and not sexually active.
All assessments normal
Diagnosis- UTI
DD- Bacterial Vaginosis, STI, vulvovaginal candidiasis (yeast infection), trichomoniasis (a sexually transmitted infection)

Please answer the above questions. SOAP note template added. Please add to template. Please fill out template with assessment information. If missing information. Please change format template to APA Times roman numeral. Use clinical guidelines for treatment and websites.

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