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.
· 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.
- Case Study Assignment This week you will be reviewing another SOAP note and reflecting on the additional information that you would be needing. This is not in SOAP format, you will use headings for each section, and give me dialogue on what information is missing in each section. You will provide 5 differentials and reflect on the questions posed for the assignment. Be sure to support with scholarly references.
Special Examinations—Breast, Genital, Prostate, and Rectal GENITALIA ASSESSMENT
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, neg McBurney•Diagnostics: HSV specimen obtained
In summary, be sure to follow the rubric for this assignment. Tell me what is missing in each section…..and would you support or refute the diagnosis. Support that answer with rationale, and provide differential diagnosis with supported rationale. Utilize scholarly references to support your rationales. Remember….if you are doing a focused exam, which is what these case studies are…..be sure to really expand on the body systems that you are concerned about to hone in on your differential diagnosis. This will help you with your documentation completeness going forward.
· Based on the Episodic note case study:
o 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.
o Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
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.
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.