1. Discussion: Breast or cervical cancer
Discussion: Breast or cervical cancerDiscussion: Breast or cervical cancerIn this assignment,
you will analyze 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.GENITALIA
ASSESSMENTSubjective: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 over 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: AsthmaMedications: Symbicort
160/4.5mcgORDER NOW FOR CUSTOMIZED, PLAGIARISM-FREE PAPERSAllergies:
NKDAFH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERDSocial:
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 169lbsHeart: RRR, no murmursLungs: CTA,
chest wall symmetricalGenital: Normal female hair pattern distribution; no masses or
swelling. Urethral meatus intact without erythema or discharge. Perineum intact with a
healed episiotomy scar present. Vaginal mucosa pink and moist with rugae present, pos for
firm, round, small, painless ulcer noted on external labiaAbd: soft, normoactive bowel
sounds, neg rebound, neg murphy’s, neg McBurneyDiagnostics: HSV specimen
obtainedAssessment:ChancrePLAN: This section is not required for the assignments in this
course (NURS 6512) but will be required for future courses.To prepare:With regard to the
SOAP note case study provided:Review this week’s Learning Resources, and consider the
insights they provide about the case study.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.To complete:Refer to Chapter 5 of the
Sullivan text. Analyze the SOAP note case study. Using evidence based resources, answer the
following questions and your answers using current evidence from the literature.
2. Discussion: Breast or cervical cancerAnalyze 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 ed 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 3 different references from current evidence
based literature.
