Assessing The Genitalia And Rectum
Examining the Rectum and Genitalia
Patients typically feel awkward discussing genitalia and rectum with medical professionals, but getting a complete medical history and a thorough physical exam is important. Advanced practice nurses can be better prepared to appropriately assess patients with issues in the vaginal and rectal areas by studying case studies of these anomalies.
In this assignment, you will take into account case studies that discuss unusual discoveries in patients treated in a clinical environment.
As part of this assignment, you will examine a SOAP note case study that details aberrant findings in patients encountered in a clinical environment. You will think about what information from the patients’ histories should be obtained and what physical examinations and diagnostic testing should be performed. You will also create a differential diagnosis with several potential diseases.
• CC: “I want to have the pimples on my bottom looked at.”
• HPI: AB, a 21-year-old college student from WF who has external lumps on her vaginal region, comes to your clinic. She claims that the lumps feel scratchy and are not painful. She has been sexually active and had multiple partners the previous year. She had her first sexual encounter at the age of 18. She claims there is no unusual vaginal discharge. The pimples were first observed by her around a week ago, although she is unsure how long they have been there. Her most recent Pap smear test was performed three years ago, and the results were normal; no abnormality was discovered. She mentioned having had one chlamydia infection about two years ago. She finished the recommended course of chlamydia treatment. Essay assignment example: Evaluating the Genitalia and Rectum.
• Asthma: PMH
Symbicort 160/4.5mcg medication; NKDA allergies
• FH: No history of breast or cervical cancer, HTN in both parents, GERD.
• Social: Denies using tobacco; uses EtOH on occasion; married; has three kids (1 girl, 2 boys)
• VS: temperature 98.6, blood pressure 120/86, RR 16, pulse 92, height 5’10”, weight 169 lbs, and no heart murmurs
• Lungs: CTA, symmetrical chest wall
• Genital: Female hair is distributed normally; no lumps or swelling are present. Without erythema or discharge, the urethral meatus is intact. Intact perineum with an episiotomy scar that has healed. Rugae are present, the vaginal mucosa is pink and wet, and there is a possible firm, circular, tiny, painless ulcer on the external labia.
• Abd: mild bowel activity, negative rebound, negative Murphy’s, negative McBurney
An HSV specimen was taken for the diagnostics
• PLAN: This section will be necessary for future courses but not for the assignments in this course (NURS 6512).
To get ready:
Regarding the case study supplied for the SOAP note:
• Go over the learning resources from this week and consider the case study insights they offer.
• Take into account the history that the patient in the case study would need to provide.
• Think about what physical examinations and diagnostic testing are necessary to learn more about the patient’s condition. How could a diagnosis be made using the findings?
• List at least five potential conditions that could be included in the patient’s differential diagnosis. Essay assignment example: Evaluating the Genitalia and Rectum.
Please refer to the Sullivan text’s Chapter 5. Examine the case study on the SOAP note. Answer the following questions using evidence-based resources, and then back up your responses with recent data from the literature.
• Examine the note’s subjective section. List any additional details that the documentation should contain.
• Examine the note’s objective section. List any additional details that the documentation should contain.
• Is the evaluation backed up by both subjective and objective data? Whether or not
• Would diagnostics be appropriate in this situation, and how would a diagnosis be made using the findings?
• Do you agree or disagree with the current diagnosis? If not, why not? Name three potential conditions that could be used in this patient’s differential diagnosis. Use at least three references from recent evidence-based literature to support your arguments. Essay assignment example: Evaluating the Genitalia and Rectum.
Assessing The Genitalia And Rectum
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.