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Week 10: —Breast, Genital, Prostate, and Rectal

Posted on: Saturday, May 1, 2021 5:14:37 PM EDT

Week 10: Special —Breast, Genital, Prostate, and Rectal

*Remember this paper should be in Narrative format and NOT SOAP note*

You will ANALYZE (DETAILED) 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. The diagnostic testings/ physical exams

should be explained in detail of why they are relevant to the diagnosis given. Avoid ROS and Physical exam descriptions of

“WNL” and “normal”, you must write out the description.

*If there is any information missing, you must add it, in order to make your analysis complete*

Based on the Episodic note case study:

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 assessment was 3 years ago, and no dysplasia was found; the assessment 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.

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

Consider what history would be necessary to collect from the patient in the case study.

Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

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.