Special Examinations—Breast, Genital, Prostate, and Rectal
Special Examinations—Breast, Genital, Prostate, and Rectal
PLEASE USE REFERENCES WITHIN THE LAST 5 YEARS PLEASE.
Students will:
• Evaluate abnormal findings on the genitalia and rectum
• Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the breasts, genitalia, prostate, and rectum
GENITALIA ASSESSMENT
• Episodic note case study:
CC: Increased frequency and pain with urination
HPI:
T.S. is a 32-year-old woman who reports that for the past two days, she has dysuria, frequency, and urgency. Has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months.
Medical History:
None
Surgical History:
• Tonsillectomy in 2001
• Appendectomy in 2020
Review of Systems:
• General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
• Abdominal: Denies nausea and vomiting. No appetite
Objective
VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.
Pelvic Exam:
• mild tenderness to palpation in the suprapubic area
• bimanual pelvic examination reveals a normal-sized uterus and adnexa
• no adnexal tenderness.
• No vaginal discharge is noted.
• The cervix appears normal.
Diagnostics: Urinalysis, STI testing, Papsmear
Assessment:
• UTI
• STI
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
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.
Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum
Assignment: 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.
RUBRIC
With regard to the SOAP note case study provided and 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.–
Excellent 10 (10%) – 12 (12%)
Good 7 (7%) – 9 (9%)
Fair 4 (4%) – 6 (6%)
Poor 0 (0%) – 3 (3%)
· Analyze the objective portion of the note. List additional information that should be included in the documentation.–
Excellent 10 (10%) – 12 (12%)
Good 7 (7%) – 9 (9%)
Fair 4 (4%) – 6 (6%)
Poor 0 (0%) – 3 (3%)
· Is the assessment supported by the subjective and objective information? Why or why not?–
Excellent 14 (14%) – 16 (16%)
Good 11 (11%) – 13 (13%)
Fair 8 (8%) – 10 (10%)
Poor 0 (0%) – 7 (7%)
· What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?–
Excellent 18 (18%) – 20 (20%)
Good 15 (15%) – 17 (17%)
Fair 12 (12%) – 14 (14%)
Poor 0 (0%) – 11 (11%)
· Would you reject or accept the current diagnosis? Why or why not?
· Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.–
Excellent 23 (23%) – 25 (25%)
Good 20 (20%) – 22 (22%)
Fair 17 (17%) – 19 (19%)
Poor 0 (0%) – 16 (16%)
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.–
Excellent 5 (5%) – 5 (5%)
Good 4 (4%) – 4 (4%)
Fair 3 (3%) – 3 (3%)
Poor 0 (0%) – 2 (2%)
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation–
Excellent 5 (5%) – 5 (5%)
Good 4 (4%) – 4 (4%)
Fair 3 (3%) – 3 (3%)
Poor 0 (0%) – 2 (2%)
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.–
Excellent 5 (5%) – 5 (5%)
Good 4 (4%) – 4 (4%)
Fair 3 (3%) – 3 (3%)
Poor 0 (0%) – 2 (2%)
Total Points: 100
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