1. 6512 Assignment WK 10
Assignment 1: Assessing the Genitalia and RectumPatients are frequently uncomfortable
discussing with health care 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
assignment, you will consider case studies that describe abnormal findings in patients seen
in a clinical setting.In 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: 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 with a healed episiotomy scar present.
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,
neg McBurney· Diagnostics: HSV specimen obtainedAssessment:· Chancre· PLAN: 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
2. 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
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
3 different references from current evidence based literature.
