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)