Assessing the Genitalia and Rectum.

Assessing the Genitalia and Rectum.

Assignment: Lab Assignment: Assessing the Genitalia and Rectum.

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.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.

                                                   Case Study

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, 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. 

 
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