Assignment: Lab Assignment: Assessing the Genitalia and Rectum.

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.

                                                   Case Study

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, 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. 
 
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