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5 pages/≈1375 words
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Level:
APA
Subject:
Health, Medicine, Nursing
Type:
Case Study
Language:
English (U.S.)
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Topic:

Genitalia Assessment Health, Medicine, Nursing Case Study (Case Study Sample)

Instructions:

Instructions:
Follow the SOAP format and use the provided case study.
1- Analyze the subjective portion of the note. List additional information that should be included in the documentation.
2- Analyze the objective portion of the note. List additional information that should be included in the documentation.
3- Is the assessment supported by the subjective and objective information? Why or why not?
4- Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
5- 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?
7-Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. Explain your reasoning using at least three different references from current evidence-based literature.
8-Would you reject/accept the current diagnosis? Why or why not?
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 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:
Plan:

source..
Content:


Genitalia Assessment
Your Name
Subject and Section
Professor’s Name
Date of Submission
Date of assessment: August 9, 2020
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 five small, painless, and rough bumps along her labia majora and six on her vagina which she noticed a week ago. She is sexually active and does not use condoms or vaginal diaphragms. Before they had sex, they usually inject drugs and share the needle. She had multiple partners in the past year and some of them had multiple partners also. She began engaging in sex when she was 18 y/o. There is no vaginal discharge.
PMH: The patient has asthma since childhood but it occurs only when she runs fast or in extreme weather conditions. She was diagnosed with chlamydia 2 years ago and she completed the treatment for it. 3 years ago, she had undergone a Pap smear and the result was normal without dysplasia. She did not have any recent surgeries or hospitalizations.
Immunizations: HBsAg and Tetanus toxoid in December 2018.
Medications: Symbicort 160/4.5mcg twice daily for maintenance. Combination pill (oral contraceptives) every day for maintenance. She does not take herbal or any OTC drugs.
Allergies: NKDA
FH: No hx of breast or cervical cancer. Father has a hx of HTN. Mother has a hx of HTN, GERD
Social: Denies tobacco use; occasional etoh; (+) illicit drug use. She is married with 3 children (1 girl and 2 boys) and lives in an apartment in a village. She is a working student and goes to school every MWF from 10 AM to 3 PM. She works full-time every TTh from 8 AM to 3 PM as a barista in Starbucks and part-time during MWF from 4 PM to 8 PM. During weekends, she spends time with her family by going to the park. Her husband is also a working student which makes them financially-challenged.

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