Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum
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Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum
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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.
By Day 7 of Week 10
Submit your Assignment.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
Please save your Assignment using the naming convention “WK10Assgn1+last name+first initial.(extension)” as the name.
Click the Week 10 Assignment Rubric to review the Grading Criteria for the Assignment.
Click the Week 10 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.
Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK10Assgn+last name+first initial.(extension)” and click Open.
If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
Click on the Submit button to complete your submission.
Week #10 – Episodic Note Case Study
Posted on: Sunday, October 31, 2021 7:00:00 AM EDT
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 6 months ago, and was WNL; the exam results were normal also. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.
•PMH: Asthma
•Medications: Symbicort 160/4.5mc, NuvaRing
•Allergies: NKDA
•FH: No Hx of breast or cervical cancer, Father – Hx HTN, Mother – Hx HTN, GERD
•Social: Denies tobacco or illicit drug use; occasional ETOH, single, no children, no pregnancies
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. External genitalia – positive for multiple, small, non-tender, skin-colored, rough growths. Vaginal mucosa pink and moist with rugae present.
Abd: Soft, normoactive bowel sounds, negative rebound, negative Murphy’s, negative McBurney.
•Diagnostics: HSV specimen obtained.
Assessment:- Genital herpes
Plan: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
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