Week 10: 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 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

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

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:
- 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.
- Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
- 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.

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.

Solution:

Genitalia Assessment

Episodic SOAP Note

Patient’s Initials: A.B.

Age: 21

Gender: Female

CC: “I have bumps on my bottom that I want to have checked out.”

HPI: A.B is a 21 years old college student who presents to the clinic with external bumps on her genital area. The patient indicates that the bumps are not painful but are rough on touch. She admits to having multiple sexual partners for the last year. She started engaging in sexual activity while at 18 years. She does not have any abnormal vaginal discharge. Although she discovered the bumps in the last one week, she cannot tell when they started. The recent Pap smear assessment was conducted three years ago with negative dysplasia. In the last two years, A.B. was diagnosed with chlamydia, a sexually transmitted disease. She completed the treatment for chlamydia as prescribed by the provider.

SUBJECTIVE:

Onset: Not sure

Location: Around the groin

Duration: One week now

Status: Painless, bumpy, and rough

Aggravating Symptoms: No present aggravating symptoms are noticed

Treatment: Currently not under any medication

Severity: No pain (0 out of 10)

Medications:Symbicort 160/4.5mcg – 2 puffs twice a day

Singulair 10mg by mouth daily

Zyrtec OTC-one tablet by mouth as needed

Allergies: No Known Drug Allergies

PMH: History of Chlamydia

Past Surgical History (PSH): Not known

F.H.:No breast cancer, no cervical cancer. Father and mother havea history of Hypertension.

Social: The patient denies the consumption of tobacco, drinks ethyl alcohol occasionally. The patient has several sexual partners for the last year. The patient received her smear pap test in the past 3 years General:The patient denies chills, fever, weight loss, body weakness or weight loss.

HEENT: Eyes: Patient denies blurred vision, visual loss, yellow sclera, or double vision. Nose, Throat, ears: The patient does not complain about hearing loss, sore throat, runny nose, congestion, or sneezing.

Skin: The skin does not show any lesion apart from the genital area

Cardiovascular: The patient denies chest pain, discomfort on the chest, edema, or palpitations.

Respiratory: There are no signs of dyspnea, shortness of breath, or cough.

Gastrointestinal: The patient denies nausea denies anyabdominal pain,constipation, vomiting. Positive skin lesions on the groin region are painless yet rough.

GU: Patient denies hesitancy, dysuria, frequency, and other abnormalities. Noabnormal vaginal dischargeisother than a rough painless bump in the genital parts.

Neurological: The patient denies back pain, muscle pain, pain, or stiffness. She also denies fatigue.

Hematologic: No bruising or bleeding is reported

Lymphatics: No history of splenectomy

Psych: The patient denies anxiety or depression. No enlarged lymph nodes.

Endocrine:The patient denies heat intolerance, sweating, polydipsia, or polyuria. She denies any notable endocrine symptoms or hormone therapies.

Sexual Reproductive History: She has multiple sexual partners

OBJECTIVE

General: AAO X 4, DENIES fatigue, body weakiness, well-nourished and composed.

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. The perineum was 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 …….Please click the icon below to purchase full answer at only $10