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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.
Special Examinations—Breast, Genital, Prostate, and Rectal
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.
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.
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