Assignment: Abnormal Findings in Patients

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Assignment: Abnormal Findings in Patients

Assignment: Abnormal Findings in Patients

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In this assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

In this assignment, you will 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.

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 over 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 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

Assessment:

· Chancre

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

To prepare:

With regard to the SOAP note case study provided:

· Review this week’s Learning Resources, and consider the insights they provide about the case study.

· 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.

To complete:

Refer to Chapter 5 of the Sullivan text. Analyze the SOAP note case study. 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.

In this assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

In this assignment, you will 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.

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 over 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 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

Assessment:

· Chancre

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

To prepare:

With regard to the SOAP note case study provided:

· Review this week’s Learning Resources, and consider the insights they provide about the case study.

· 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.

To complete:

Refer to Chapter 5 of the Sullivan text. Analyze the SOAP note case study. 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.

You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.

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