Task: Assessing The Genitalia And Rectum<\/p>\n
In this assignment you will be required to write a Focused SOAP note, please do not submit a Complete SOAP note, you must learn to differentiate the two. If you do not have enough information to make a scholarly Focused note, you may make up information. For example, if the Family History is missing make up a history.<\/p>\n
The Lab Assignment<\/p>\n
Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.<\/p>\n
\u00b7 Analyze the subjective portion of the note. List additional information that should be included in the documentation.<\/p>\n
\u00b7 Analyze the objective portion of the note. List additional information that should be included in the documentation.<\/p>\n
\u00b7 Is the assessment supported by the subjective and objective information? Why or why not?<\/p>\n
\u00b7 Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?<\/p>\n
\u00b7 Would you reject\/accept the current diagnosis? Why or why not?<\/p>\n
Identify three possible conditions that may be considered as a differential diagnosis for this patient.<\/p>\n
\u00b7 Explain your reasoning using at least three different references from current evidence-based literature.<\/p>\n
Week 10: Special Examinations\u2014Breast, Genital,<\/p>\n
Prostate, and Rectal<\/p>\n
GENITALIA ASSESSMENT<\/p>\n
Subjective:<\/p>\n
\u2022 CC: \u201cI have bumps on my bottom that I want to have checked out.\u201d<\/p>\n
\u2022 HPI: AB, a 21-year-old WF college student reports to your clinic with external<\/p>\n
bumps on her genital area. She states the bumps are painless and feel rough.<\/p>\n
She states she is sexually active and has had more than one partner during the<\/p>\n
past year. Her initial sexual contact occurred at age 18. She reports no abnormal<\/p>\n
vaginal discharge. She is unsure how long the bumps have been there but<\/p>\n
noticed them about a week ago. Her last Pap smear exam was 3 years ago, and<\/p>\n
no dysplasia was found; the exam results were normal. She reports one sexually<\/p>\n
transmitted infection (chlamydia) about 2 years ago. She completed the<\/p>\n
treatment for chlamydia as prescribed.<\/p>\n
\u2022 PMH: Asthma<\/p>\n
\u2022 Medications: Symbicort 160\/4.5mcg<\/p>\n
\u2022 Allergies: NKDA<\/p>\n
\u2022 FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD<\/p>\n
\u2022 Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)<\/p>\n
Objective:<\/p>\n
\u2022 VS: Temp 98.6; BP 120\/86; RR 16; P 92; HT 5\u201910\u201d; WT 169lbs<\/p>\n
\u2022 Heart: RRR, no murmurs<\/p>\n
\u2022 Lungs: CTA, chest wall symmetrical<\/p>\n
\u2022 Genital: Normal female hair pattern distribution; no masses or swelling. Urethral<\/p>\n
meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa<\/p>\n
pink and moist with rugae present, pos for firm, round, small, painless ulcer noted<\/p>\n
on external labia<\/p>\n
\u2022 Abd: soft, normoactive bowel sounds, neg rebound, neg murphy\u2019s, negMcBurney<\/p>\n
\u2022 Diagnostics: HSV specimen obtained<\/p>\n
Assessment:<\/p>\n
\u2022 Chancre<\/p>\n","protected":false},"excerpt":{"rendered":"
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