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Assignment: Lab Assignment: Assessing the Genitalia and Rectum

Assignment: Lab Assignment: Assessing the Genitalia and Rectum

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Assignment: Lab Assignment: Assessing the Genitalia and Rectum  

· Assignment: Lab Assignment: Assessing the Genitalia and Rectum

.

. Refer to Chapter 3 of the Sullivan resource to guide you as you

. .

. 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.

. PLEASE DO NOT copy this SOAP note to your final copy of your paper for submission.

       

 Below is the Episodic SOAP Note.

    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

The Lab Assignment

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.

· .

· This is to be a NARRATIVE (PARAGRAPHS). Answer each question. PLEASE DO NOT submit anything other than the responses to the questions. You DO NOT need to submit a SOAP note.

·

Assignment: Lab Assignment: Assessing

the Genitalia and Rectum

o

o

Refer

to

Chapter

3

of

the

Sullivan

resource

to

guide

you

as

you

o

.

o

Consider

what

history

would

be

necessary

to

co

llect

from

the

patient

in

the

case

study.

o

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?

o

Identify

at

least

five

possible

co

nditions

that

may

be

considered

in

a

differential

diagnosis

for

the

patient.

o

PLEASE

DO

NOT

copy

this

SOAP

note

to

your

final

copy

of

your

paper

for

submission.

Below

is

the

Episodic

SOAP

Note.

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

stat

es

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

·

Medication

s:

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)

 Assignment: Lab Assignment: Assessing

the Genitalia and Rectum

o

o Refer to Chapter 3 of the Sullivan resource to guide you as you

o .

o Consider what history would be necessary to collect from the

patient in the case study.

o 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?

o Identify at least five possible conditions that may be considered in

a differential diagnosis for the patient.

o PLEASE DO NOT copy this SOAP note to your final copy of your

paper for submission.

Below is the Episodic SOAP Note.

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)

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