Assessing the Genitalia and Rectum
· Assignment: Lab Assignment: Assessing the Genitalia and Rectum
.
. Refer to Chapter 3 of the Sullivan resource to guide you as you
. .
. 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.
. PLEASE DO NOT copy this SOAP note to your final copy of your paper for submission.
Below is the Episodic SOAP Note.
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
The Lab Assignment
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.
· .
· This is to be a NARRATIVE (PARAGRAPHS). Answer each question. PLEASE DO NOT submit anything other than the responses to the questions. You DO NOT need to submit a SOAP note.
Assignment: Lab Assignment: Assessing
the Genitalia and Rectum
o
o
Refer
to
Chapter
3
of
the
Sullivan
resource
to
guide
you
as
you
o
.
o
Consider
what
history
would
be
necessary
to
co
llect
from
the
patient
in
the
case
study.
o
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?
o
Identify
at
least
five
possible
co
nditions
that
may
be
considered
in
a
differential
diagnosis
for
the
patient.
o
PLEASE
DO
NOT
copy
this
SOAP
note
to
your
final
copy
of
your
paper
for
submission.
Below
is
the
Episodic
SOAP
Note.
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
stat
es
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
·
Medication
s:
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)
Assignment: Lab Assignment: Assessing
the Genitalia and Rectum
o
o Refer to Chapter 3 of the Sullivan resource to guide you as you
o .
o Consider what history would be necessary to collect from the
patient in the case study.
o 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?
o Identify at least five possible conditions that may be considered in
a differential diagnosis for the patient.
o PLEASE DO NOT copy this SOAP note to your final copy of your
paper for submission.
Below is the Episodic SOAP Note.
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)