Genitalia and Rectum Assessment Paper
analyze a SOAP 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.
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 over the past year. Her initial sexual contact occurred at age 18.Genitalia and Rectum Assessment Paper. 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.
Medications: Symbicort 160/4.5mcg
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)
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 with a healed episiotomy scar present. 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
With regard to the SOAP note case study 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.
Using evidence based resources, 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 3 different references from current evidence based literature.
Refreces to include in paper
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016)Genitalia and Rectum Assessment Paper. Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 5, “Amenorrhea” (pp. 47-60)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel\'s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 16,18, 19 20. Genitalia and Rectum Assessment Paper