Health Assessment Case Study

For this 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.

Review the following Episodic note case study:

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

·       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.

Please complete in a narrative format so you can explain your thoughts fully. Do not add information in an episodic note format)

• 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.