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Week Ten: Special Examinations – Breast, Genital, Prostate, and Rectal

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Week 10: Special Examinations—Breast, Genital, Prostate, and Rectal
Posted on: Monday, April 27, 2020 8:57:13 PM EDT
Week 10: Special Examinations—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.
*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 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.
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.
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.

Essay Sample Content Preview:

Week Ten: Special Examinations – Breast, Genital, Prostate, and Rectal
Your Name
Subject and Section
Professor’s Name
May 1, 2020
For patients that exhibit genitourinary symptoms, in this case, painless lumps, the necessity of clear and comprehensive history documentation is necessary. This must be further probed by a thorough examination of other areas of the body, such as the chest, throat, neck, and rectum. In this paper, the author will present my analysis in four parts. First, an analysis of the subjective data and then provide additional information that must be probed from the patient will be provided. Second, the objective data and introduce other possible tests that must be done to support the diagnostics further will be discussed. Third, the assessment of the diagnosis to check if it coincides with the subjective and objective data will be probed. Lastly, the author will be providing other possible diagnostics for the patient.
Analysis of Subjective Data
The subjective part of this Episodic SOAP note should also include more physical symptoms such as fevers, nausea, vomiting, changes in bowel movement, or discomfort. Furthermore, the patient should be probed further for a more specific description of the bumps, such as their shape, pattern, size and colour, and specific location (inner or outer vulva and the clitoral area). How the bumps were discovered by the patient should also be clarified, as it was not specified if the lumps had hurt at some point before or if other aggravated symptoms led to the discovery of the lumps. Despite the lumps being on the external genitalia, it is also essential to know if she has felt other kinds of discomfort internally. History of other lesions in the genitals and other parts of the body should have also been probed. Hygiene habits for the genital area must also be asked, primarily if the patient uses douches, topical medication, and fragrant soaps.
Skin conditions such as psoriasis, dermatitis, or eczema must be asked from the patient. Asthma management, as well as the age of diagnosis, and if possible immunization records and gynaecological surgeries, must be probed further from the patient.
More importantly, gynaecological history must be documented before a further assessment, in case of a possible pregnancy. A record of the patient's menstrual pattern is vital for this, and thus the date of the last menstrual period, volume, and duration of menstrual flow and contraception use should be checked. Post-coital bleeding—if any should be included, as well as the history of dyspareunia and itchiness in the vulva. Previous dates and duration of medication for STI’s, in this case, Chlamydia, should be documented too.
Since the patient has multiple children, it is necessary to probe her obstetric history. Like the menstrual pattern, this will help assess other possible health risks. 
Analysis of Objective Data
The initial diagnosis of Chancre must be further assessed by doing other tests. Assessment for abnormalities in the throat area, such as redness, other lesions, cold sores, oral thrush, tonsil enlargement must be included on the HEENT exam to check for HSV or other viral infections. Additional information, such as lumps or m...
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