ASSESSING THE GENITALIA AND RECTUM

ASSIGNMENT

LAB ASSIGNMENT: ASSESSING THE GENITALIA AND RECTUM

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.

RESOURCES

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.

Chapter 17, “Breasts and Axillae”
This chapter focuses on examining the breasts and axillae. The authors describe the examination procedures and the anatomy and physiology of breasts.

• Chapter 19, “Female Genitalia”
  In this chapter, the authors explain how to conduct an examination of female genitalia. The chapter also describes the form and function of female genitalia.

Chapter 20, “Male Genitalia”
The authors explain the biology of the penis, testicles, epididymides, scrotum, prostate gland, and seminal vesicles. Additionally, the chapter explains how to perform an exam of these areas.

Chapter 21, “Anus, Rectum, and Prostate”
This chapter focuses on performing an exam of the anus, rectum, and prostate. The authors also explain the anatomy and physiology of the anus, rectum, and prostate.

• Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
  Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

• Chapter 3, “SOAP Notes” (Previously read in Week 8)

Centers for Disease Control and Prevention. (2021, April 13). Sexually transmitted disease surveillance, 2019Links to an external site..Links to an external site. https://www.cdc.gov/std/#
This section of the CDC website provides a range of information on sexually transmitted diseases (STDs). The website includes reports on STDs, related projects and initiatives, treatment information, and program tools.

•        TO PREPARE    

Review the Episodic note case study 

• Based on the Episodic note case study:

Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.

Search the Walden library or 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.

• Episodic note case study: Genitalia Assessment listed below.

Genitourinary Assessment

CC: Increased frequency and pain with urination

• HPI:

T.S. is a 32-year-old woman who reports that for the past two days, she has dysuria, frequency, and urgency. Has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months.

• Medical History:

None

Surgical History:

Tonsillectomy in 2001

Appendectomy in 2020

Review of Systems:

General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.

• Abdominal: Denies nausea and vomiting. No appetite
• Objective 

VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.

• Pelvic Exam:
• mild tenderness to palpation in the suprapubic area
• bimanual pelvic examination reveals a normal-sized uterus and adnexae
• no adnexal tenderness.
• No vaginal discharge is noted.

The cervix appears normal.

Diagnostics: Urinalysis, STI testing, Papsmear

Assessment:

UTI

STI

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

                 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.

Assignment1_Rubric

Criteria

With regard to the SOAP note case study provided and 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.

Ans.

The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation.