nurs6512 Week 10 assignment Assessing the Genitalia and Rectum latest 2018 april

Week 10
assignment

Assignment 1: Assessing the Genitalia and Rectum

Patients are frequently uncomfortable discussing with health
care 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 assignment, you will consider case studies that
describe abnormal findings in patients seen in a clinical setting.

In this assignment, you will analyze 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.

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 over 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 with a healed episiotomy scar present. 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

Assessment:

Chancre

PLAN: This section is not required for the assignments in
this course (NURS 6512) but will be required for future courses.

To prepare:

With regard to the SOAP note case study provided:

Review this week’s Learning Resources, and consider the
insights they provide about the case study.

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.

To complete:

Refer to Chapter 5 of the Sullivan text. Analyze the SOAP
note case study. Using evidence based
resources, 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
3 different references from current evidence based literature.

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