PLEASE FOLLOW THE INSTRUCTIONS AS INDICATED BELOW:

1). ZERO (0) PLAGIARISM

2). AT LEAST 5 REFERENCES, NO MORE THAN 5 YEARS (WITHIN 5YRS, OR LESS THAN 5YRS)

3). PLEASE SEE THE ATTACHMENT FOR RUBRIC DETAILS AND EPISODIC/FOCUSED NOTE TEMPLATE

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.

Special Examinations—Breast, Genital, Prostate, and Rectal

GENITALIA 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

PLAN: This section is not required for the assignments in this course (NURS 6512) but

will be required for future courses.

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.

Rubric Detail

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Content

Name: NURS_6512_Week_10_Assignment_Rubric

  Excellent Good Fair Poor
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.

Points:

Points Range:
10 (10%) – 12 (12%)

The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation.

Feedback:

Points:

Points Range:
7 (7%) – 9 (9%)

The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.

Feedback:

Points:

Points Range:
4 (4%) – 6 (6%)

The response vaguely analyzes the subjective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.

Feedback:

Points:

Points Range:
0 (0%) – 3 (3%)

The response inaccurately analyzes the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.

Feedback:

·   Analyze the objective portion of the note. List additional information that should be included in the documentation.

Points:

Points Range:
10 (10%) – 12 (12%)

The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation.

Feedback:

Points

Episodic/Focused SOAP Note Template

 

Patient Information:

Initials, Age, Sex, Race


S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing