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APA
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Health, Medicine, Nursing
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Coursework
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English (U.S.)
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Topic:

Genitalia Assessment: Individual and Objective Information in the Medical Report

Coursework Instructions:

Week 10 Genitalia Assessment
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, 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.

Coursework Sample Content Preview:

Genitalia Assessment
Author’s Name
Institutional Affiliation
Genitalia Assessment
Introduction
The patient who is suffering from genitourinary signs, it is important to focus on the given medical history. There are chances that the genitourinary issue causes various other problems in the body. The quality of life badly affected by the worse medical condition of the patient (Dains, Baumann & Scheibal, 2016). An accurate diagnosis is possible with authentic nursing skills. In the current study, additional information regarding subjective and objective records has been discussed that should be incorporated in the assessment of Patient presenting with genitourinary issues.
Additional Individual Information to Include In the Medical Report
To assess the current condition of the patient and to provide a possible conclusion regarding the disease, there is need to ask additional information about symptoms that are linked with bumps such as shape, color, pattern, and size. It is also important to know that if the patient experienced the bumps for the first time or she experienced it multiple times in the past. In there any medicine that was taken in the past to cure bumps. Some of the patients who are facing a problem with genitourinary tract experience different symptoms such as fatigue, hair loss, sores on anus, instant weight loss, fever, skin rash, and dysuria (Dains, Baumann & Scheibal, 2016). The patient will be asked about the usage of soaps, douches, and fragrances. The information regarding gynecological history may provide risks related to HIV (Jensen 2018). The risk of STI is possible in the future.
Additional Objective Information Include in the Medical Report
The patient is married and the mother of three kids, one daughter, and two sons. For that reason, it is mandatory to know about her obstetric history. The risks regarding the health of the patient can be identified with the help of obstetric history. The objective information regarding patient’s hygiene, mentoring, and physique is essential. Some symptoms are helpful to analyze infections from HSV or other viruses that include lesions, edema, cold sores, redness, oral thrush, and enlarged tonsils (Seidel, et al., 2015). Chest examination and nasal flaring are required to be documented.
If the Assessment is Supported by Objective or Subjective Information
As per the assessment, it has been concluded that the patient has Chancre. It normally occurs in the genital region. It takes 3 weeks to 3 months to identify the Chancre infection. A chancre is a type of painless ulcer (Dains, Baumann & Scheibal, 2016). It is extremely infectious and it causes the initial stage of syphilis. The patient at the genital area experienced the rough lump as per subjective information. As per objective information, the patient had developed small and round ulcer at the eternal l...
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