NURS 6512 week 10 Assignment: Lab Assignment: Assessing the Genitalia and Rectum
NURS 6512 week 10 Assignment : 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.
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.NURS 6512 week 10 Assignment
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?NURS 6512 week 10 Assignment
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. NURS 6512 week 10 Assignment
NURS 6512 week 10 Assignment Answer
Genitalia Assessment
Episodic SOAP Note
Patient’s Initials: A.B.
Age: 21
Gender: Female
Chief Complaint (CC): “I have bumps on my bottom that I want to have checked out.”
History of Present Illness (HPI): A.B. is a 21-year-old college student who has presented to the clinic with external bumps on her genital area. These bumps are not painful but feel rough to the touch. She reports having had multiple sexual partners for the past year, starting her sexual activity at 18. There is no abnormal vaginal discharge. A.B. noticed the bumps within the last week but is uncertain about when they first appeared. Her most recent Pap smear assessment, conducted three years ago, showed no dysplasia. She was diagnosed with chlamydia, a sexually transmitted disease, two years ago and completed the prescribed treatment. NURS 6512 week 10 Assignment
Subjective:
Onset: Not sure
Location: Around the groin
Duration: One week
Status: Painless, bumpy, and rough
Aggravating Symptoms: No present aggravating symptoms
Treatment: Currently not on any medication
Severity: No pain (0 out of 10)
Medications: Symbicort 160/4.5mcg – 2 puffs twice a day, Singulair 10mg by mouth daily, Zyrtec OTC – one tablet by mouth as needed
Allergies: No Known Drug Allergies
Past Medical History (PMH): History of Chlamydia
Past Surgical History (PSH): None known
Family History (F.H.): No history of breast or cervical cancer. Father and mother have a history of hypertension
Social: Denies tobacco use, occasional ethyl alcohol consumption, and reports having multiple sexual partners in the last year. Last smear pap test conducted within the past 3 years.
Review of Systems:NURS 6512 week 10 Assignment
General: Denies chills, fever, weight loss, body weakness.
HEENT: Denies vision issues, hearing loss, sore throat, runny nose, congestion, or sneezing.
Skin: Apart from the genital area, no other skin lesions.
Cardiovascular: Denies chest pain, discomfort, edema, or palpitations.
Respiratory: No dyspnea, shortness of breath, or cough.
Gastrointestinal: Denies nausea, abdominal pain, constipation, vomiting. Reports painless rough bump in the groin.
Genitourinary (GU): Denies hesitancy, dysuria, frequency. Reports no abnormal vaginal discharge apart from the rough painless bump in the genital area.
Neurological: Denies back pain, muscle pain, stiffness, and fatigue.
Hematologic: No bruising or bleeding reported.
Lymphatics: No history of splenectomy.
Psychiatric: Denies anxiety or depression. No enlarged lymph nodes.
Endocrine: Denies heat intolerance, sweating, polydipsia, polyuria, or any notable endocrine symptoms or hormone therapies.
Sexual Reproductive History: Multiple sexual partners.
Objective:
General: Alert and oriented, denies fatigue or weakness, well-nourished and composed.
Vital Signs: Temperature 98.6°F, Blood Pressure 120/86 mm Hg, Respiratory Rate 16 breaths per minute, Pulse 92 beats per minute, Height 5’10”, Weight 169 lbs.
Cardiovascular: Regular rate and rhythm, no murmurs.
Lungs: Clear to auscultation, chest wall symmetrical.
Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. The perineum was intact. Vaginal mucosa pink and moist with rugae present, with a firm, round, small, painless ulcer noted on external labia.
Abdomen: Soft, normoactive bowel sounds, no rebound tenderness, negative Murphy’s sign, and negative McBurney’s sign.NURS 6512 week 10 Assignment
