Week 10 Health Assessment
38622The assignment for this week is an analysis of a SOAP note for the genitalia/rectum. As in the previous SOAP note analysis, this should be completed in a narrative format and answer all the questions listed in the assignment within the module. Please remember to use the rubric to complete the assignment.
Genitourinary Assessment:
Subjective:
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 adnexae
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.
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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