Patients are frequently uncomfortable discussing with healthcare professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital. Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to accurately assess patients with problems in these areas.
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.
To Prepare
Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
Based on the Episodic note case study:
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.
Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
Consider what history would be necessary to collect from the patient in the case study.
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?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
The Lab Assignment
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.
By Day 7 of Week 10
Submit your Assignment.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
Please save your Assignment using the naming convention “WK10Assgn1+last name+first initial.(extension)” as the name.
Click the Week 10 Assignment Rubric to review the Grading Criteria for the Assignment.
Click the Week 10 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.
Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK10Assgn+last name+first initial.(extension)” and click Open.
If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
Click on the Submit button to complete your submission.
Please Read Carefully: Week 10 Analysis Guidance FYI
Posted on: Monday, November 1, 2021 7:20:45 PM EDT
FYI:
Please Do Not Submit a SOAP note for this assignment.
Week 10 Analysis Assignment is very similar to Week 6 Assignment. If you scored well on that assignment, please continue to use the rubric and analytical thinking to complete this assignment. If you did not score as well as you wanted on Week 6 Assignment, please read the specific feedback given, make sure that you are utilizing the rubric and that you are writing in narrative format and not SOAP format.
Please DO NOT rewrite or summarize the information that is already given, you are to ANALYZE it (what does the information given mean in relationship to the diagnosis?)
Posted by: Christina Stevenson
Posted to: NURS-6512C-3/NURS-6512N-3-Advanced Health Assessment-2021-Fall-QTR-Term-wks-1-thru-11-(08/30/2021-11/14/2021)-PT27
Week 10: Special Examinations—Breast, Genital, Prostate, and Rectal
Posted on: Saturday, October 30, 2021 6:47:52 PM EDT
Week 10: Special Examinations—Breast, Genital, Prostate, and Rectal
*Remember this paper should be in Narrative format and NOT SOAP note*
You will ANALYZE (DETAILED) a SOAP 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. The diagnostic testings/ physical exams
should be explained in detail of why they are relevant to the diagnosis given. Avoid ROS and Physical exam descriptions of
“WNL” and “normal”, you must write out the description.
*If there is any information missing, you must add it, in order to make your analysis complete*
Based on the Episodic note case study:
GENITALIA ASSESSMENT
Subjective:
CC: “I have bumps on my bottom that I want to have checked out.”
HPI: AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner during the past year. Her initial sexual contact occurred at age 18. She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.
PMH: Asthma
Medications: Symbicort 160/4.5mcg
Allergies: NKDA
FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD
Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia.
Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, negMcBurney
Diagnostics: HSV specimen obtained
Assessment:
Chancre
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
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
Consider what history would be necessary to collect from the patient in the case study.
Identify at least three possible conditions that may be considered in a differential diagnosis for the patient.
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.
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