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. Assessing the Genitalia and Rectum Essay Assignment Example.
• 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. Assessing the Genitalia and Rectum Essay Assignment Example.
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. Assessing the Genitalia and Rectum Essay Assignment Example.
Introduction
For clients who present with genitourinary symptoms, it is necessary that a focused and comprehensive history is taken followed by a thorough examination. Genitourinary problems are likely to trigger issues in other systems of the body. Similarly, difficulties that may arise in the various systems are likely to affect the quality of life and overall well-being of a client. Clinical nursing skills should possibly result in a list of the potential differential diagnoses and the definite diagnosis. With this approach, it is certain that a clinician will focus on the most appropriate tests that can confirm the diagnosis. This paper is an extensive discussion of the additional subjective and objective data that should be included in the assessment of clients presenting with genitourinary problems. A description of the use of diagnostics in making a diagnosis and possible differential diagnoses will also be provided. Assessing the Genitalia and Rectum Essay Assignment Example.
Additional Subjective Data to Include in the documentation.
The client will be asked to provide more information about additional symptoms associated with the bumps as I examine them to
Order this paper