Description
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 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 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 obtained
Assessment:
- 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 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.
