Medical and Health Assessment

Medical and Health Assessment

1. Case Study Assignment This week you will be reviewing another SOAP note and reflecting on the additional information that you would be needing. ,This is not in SOAP format you will use headings for each section, and give me dialogue on what information is missing in each section. You will provide 5 differentials and reflect on the questions posed for the assignment. Be sure to support with scholarly references.

Week 10: 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, 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 course

In summary, be sure to follow the rubric for this assignment. Tell me what is missing in each section…..and would you support or refute the diagnosis. Support that answer with rationale, and provide differential diagnosis with supported rationale. Utilize scholarly references to support your rationales. Remember….if you are doing a focused exam, which is what these case studies are…..be sure to really expand on the body systems that you are concerned about to hone in on your differential diagnosis. This will help you with your documentation completeness going forward.

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