NURS 6512 MTSU W 10 Genitalia Assessment Case Analysis

Subjective:

CC: “I have bumps on my bottom that I want to have checked out.”

HPI: AB, a 21-year-old WF college student who has external bumps on her genital region comes to your clinic. She claims that the lumps feel rough and are not painful. She claims to be sexually active and to have had multiple partners in the previous year. She had her first sexual encounter at the age of 18. She claims there is no unusual vaginal discharge.

The bumps were first noticed by her about a week ago, but 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 dysplasia was discovered. She mentions having had one chlamydia infection about two years ago. She finished the recommended course of chlamydia treatment. NURS 6512 MTSU W 10 Genitalia Assessment Case Analysis

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:

Chance

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. NURS 6512 MTSU W 10 Genitalia Assessment Case Analysis

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. NURS 6512 MTSU W 10 Genitalia Assessment Case Analysis

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:
  • Search 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. NURS 6512 MTSU W 10 Genitalia Assessment Case Analysis

APA format 2 pages not including title and reference page