\u00a0
\nPatients are frequently uncomfortable discussing with healthcare professional\u2019s 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.
\nIn 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.
\nTo Prepare<\/p>\n
Review the Episodic note case study your instructor provides you for this week\u2019s Assignment. Please see the \u201cCourse Announcements\u201d section of the classroom for your Episodic note case study.
\nBased on the Episodic note case study:<\/p>\n
Review this week\u2019s 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.
\nSearch the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
\nConsider what history would be necessary to collect from the patient in the case study.
\nConsider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\u2019s condition. How would the results be used to make a diagnosis?
\nIdentify\u00a0at least five\u00a0possible conditions that may be considered in a differential diagnosis for the patient.<\/p>\n
The Lab Assignment
\nUsing evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.<\/p>\n
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
\nAnalyze the objective portion of the note. List additional information that should be included in the documentation.
\nIs the assessment supported by the subjective and objective information? Why or why not?
\nWould diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
\nWould 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.<\/p>\n
EPISODIC CASE STUDY
\n\u00a0Week 10: Special Examinations\u2014Breast, Genital, Prostate, and Rectal GENITALIA ASSESSMENT\u00a0
\nSubjective:\u00a0
\n\u2022 CC: \u201cI have bumps on my bottom that I want to have checked out.\u201d\u00a0
\n\u2022 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.
\n\u00a0\u2022 PMH: Asthma \u2022 Medications: Symbicort 160\/4.5mcg\u00a0
\n\u2022 Allergies: NKDA \u2022 FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD\u00a0
\n\u2022 Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
\n\u00a0Objective:\u00a0
\n\u2022 VS: Temp 98.6; BP 120\/86; RR 16; P 92; HT 5\u201910\u201d; WT 169lbs\u00a0
\n\u2022 Heart: RRR, no murmurs\u00a0
\n\u2022 Lungs: CTA, chest wall symmetrical\u00a0
\n\u2022 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\u00a0
\n\u2022 Abd: soft, normoactive bowel sounds, neg rebound, neg murphy\u2019s, negMcBurney
\n\u2022 Diagnostics: HSV specimen obtained
\n\u00a0Assessment:\u00a0
\n\u2022 Chancre\u00a0
\nPLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.\u00a0<\/p>\n","protected":false},"excerpt":{"rendered":"
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