Order ID:89JHGSJE83839 | Style:APA/MLA/Harvard/Chicago | Pages:5-10 |
Instructions:
Assignment: Lab Assignment: Assessing the Genitalia and Rectum
.
. Refer to Chapter 3 of the Sullivan resource to guide you as you
. .
. 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 patients 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.
. PLEASE DO NOT copy this SOAP note to your final copy of your paper for submission.
Below is the Episodic SOAP Note.
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 510; 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 murphys, negMcBurney
Diagnostics: HSV specimen obtained
Assessment:
Chancre
The Lab Assignment
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.
.
This is to be a NARRATIVE (PARAGRAPHS). Answer each question. PLEASE DO NOT submit anything other than the responses to the questions. You DO NOT need to submit a SOAP note.
Assignment: Lab Assignment: Assessing
Assignment: Lab Assignment: Assessing
the Genitalia and Rectum
o
o Refer to Chapter 3 of the Sullivan resource to guide you as you
o .
o Consider what history would be necessary to collect from the
patient in the case study.
o Consider what physical exams and diagnostic tests would be
appropriate to gather more information about the patients
condition. How would the results be used to make a diagnosis?
o Identify at least five possible conditions that may be considered in
a differential diagnosis for the patient.
o PLEASE DO NOT copy this SOAP note to your final copy of your
paper for submission.
Below is the Episodic SOAP Note.
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)
RUBRIC |
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Excellent Quality 95-100%
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Introduction
45-41 points The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned. |
Literature Support 91-84 points The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned. |
Methodology 58-53 points Content is well-organized with headings for each slide and bulleted lists to group related material as needed. Use of font, color, graphics, effects, etc. to enhance readability and presentation content is excellent. Length requirements of 10 slides/pages or less is met. |
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Average Score 50-85% |
40-38 points More depth/detail for the background and significance is needed, or the research detail is not clear. No search history information is provided. |
83-76 points Review of relevant theoretical literature is evident, but there is little integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are included. Summary of information presented is included. Conclusion may not contain a biblical integration. |
52-49 points Content is somewhat organized, but no structure is apparent. The use of font, color, graphics, effects, etc. is occasionally detracting to the presentation content. Length requirements may not be met. |
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Poor Quality 0-45% |
37-1 points The background and/or significance are missing. No search history information is provided. |
75-1 points Review of relevant theoretical literature is evident, but there is no integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are not included in the summary of information presented. Conclusion does not contain a biblical integration. |
48-1 points There is no clear or logical organizational structure. No logical sequence is apparent. The use of font, color, graphics, effects etc. is often detracting to the presentation content. Length requirements may not be met |
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Assessing the Genitalia and Rectum