Episodic note Case Study :  Special Examinations—Breast, Genital, Prostate, and Rectal  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 state: s 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. Assignment: Assessing the Genitalia and Rectum Patients are frequently uncomfortable discussing with healthcare professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital. Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to accurately assess patients with problems in these areas. 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: o 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. o Sea.

1. Episodic note Case Study
: Special Examinations—Breast, Genital, Prostate, and Rectal
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 state: s 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)

2. 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.
Assignment: Assessing the Genitalia and Rectum
Patients are frequently uncomfortable discussing with
healthcare professional’s issues that involve the genitalia and
rectum; however, gathering an adequate history and properly
conducting a physical exam are vital. Examining case studies of
genital and rectal abnormalities can help prepare advanced
practice nurses to accurately assess patients with problems in
these areas.
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

3. Announcements” section of the classroom for your Episodic
note case study.
· Based on the Episodic note case study:
o 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.
o Search the Walden library or the Internet for evidence-based
resources to support your answers to the questions provided.
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.
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.

4. · 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.
Resources for reference ( need 3 + references)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2019).
Seidel's guide to physical examination: An interprofessional
approach
(9th ed.). St. Louis, MO: Elsevier Mosby.
· Chapter 17, “Breasts and Axillae”
This chapter focuses on examining the breasts and axillae. The
authors describe the examination procedures and the anatomy
and physiology of breasts.
· Chapter 19, “Female Genitalia”
In this chapter, the authors explain how to conduct an
examination of female genitalia. The chapter also describes the
form and function of female genitalia.
· Chapter 20, “Male Genitalia”

5. The authors explain the biology of the penis, testicles,
epididymides, scrotum, prostate gland, and seminal vesicles.
Additionally, the chapter explains how to perform an exam of
these areas.
· Chapter 21, “Anus, Rectum, and Prostate”
This chapter focuses on performing an exam of the anus,
rectum, and prostate. The authors also explain the anatomy and
physiology of the anus, rectum, and prostate.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019).
Advanced health assessment and clinical diagnosis in primary
care
(6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical
Diagnosis in Primary Care, 6th Edition by Dains, J.E.,
Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby.
Reprinted by permission of Mosby via the Copyright Clearance
Center.
Chapter 5, “Amenorrhea”
Amenorrhea, or the absence of menstruation, is the focus of
this chapter. The authors include key questions to ask patients
when taking histories and explain what to look for in the
physical exam.
Chapter 6, “Breast Lumps and Nipple Discharge”
This chapter focuses on the important topic of breast lumps and
nipple discharge. Because breast cancer is the most common

6. type of cancer in women, it is important to get an accurate
diagnosis. Information in the chapter includes key questions to
ask and what to look for in the physical exam.
Chapter 7, “Breast Pain”
Determining the cause of breast pain can be difficult. This
chapter examines how to determine the likely cause of the pain
through diagnostic tests, physical examination, and careful
analysis of a patient’s health history.
Chapter 27, “Penile Discharge”
The focus of this chapter is on how to diagnose the causes of
penile discharge. The authors include specific questions to ask
when gathering a patient’s history to narrow down the likely
diagnosis. They also give advice on performing a focused
physical exam.
Chapter 36, “Vaginal Bleeding”
In this chapter, the causes of vaginal bleeding are explored.
The authors focus on symptoms outside the regular menstrual
cycle. The authors discuss key questions to ask the patient as
well as specific physical examination procedures and laboratory
studies that may be useful in reaching a diagnosis.
Chapter 37, “Vaginal Discharge and Itching”
This chapter examines the process of identifying causes of
vaginal discharge and itching. The authors include questions on
the characteristics of the discharge, the possibility of the issues
being the result of a sexually transmitted infection, and how
often the discharge occurs. A chart highlights potential
diagnoses based on patient history, physical findings, and
diagnostic studies.

7. Sullivan, D. D. (2019).
Guide to clinical documentation
(3rd ed.). Philadelphia, PA: F. A. Davis.
· Chapter 3, "SOAP Notes"
Cucci, E., Santoro, A., DiGesu, C., DiCerce, R., & Sallustio, G.
(2015). Sclerosing adenosis of the breast: Report of two cases
and review of the literature.
Polish Journal of Radiology, 80
, 122–127. doi:10.12659/PJR.892706. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4356184/
Sabbagh , C., Mauvis, F., Vecten, A., Ainseba, N., Cosse, C.,
Diouf, M., & Regimbeau, J. M. (2014). What is the best position
for analyzing the lower and middle rectum and sphincter
function in a digital rectal examination? A randomized,
controlled study in men.
Digestive and Liver Disease, 46
(12), 1082–1085. doi:10.1016/j.dld.2014.08.045
Westhoff , C. L., Jones, H. E., & Guiahi, M. (2011). Do new
guidelines and technology make the routine pelvic examination
obsolete?
Journal of Women’s Health, 20
(1), 5–10.
This article describes the benefits of new technology and
guidelines for pelvic exams. The authors also detail which
guidelines and technology may become obsolete.
Centers for Disease Control and Prevention. (2019).
Sexually transmitted diseases (STDs).
Retrieved from http://www.cdc.gov/std/#

8. This section of the CDC website provides a range of
information on sexually transmitted diseases (STDs). The
website includes reports on STDs, related projects and
initiatives, treatment information, and program tools.