Patients are frequently uncomfortable discussing with health care professionals 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.
In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
Case 3: Genitalia
A 21-year-old college student reports to your clinic with external bumps on her genital area. The bumps are painless and feel rough. The patient is sexually active and has had more than one partner over the past year. Her initial sexual contact occurred at age 18. The patient 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 had one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.
With regard to the case study you were assigned:
· 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 you were assigned.
· 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.
Post a Soap note
1. a description of the health history you would need to collect from the patient in the case study to which you were assigned.
2. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.
3. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Please read below regarding discussion case study posts
Your response should be in soap note format
But you don’t have to make up any information. If information is not provided in the case study do not add it. State: None or information not provided.
For the additional history questions you need to come up with appropriate questions that applies to case study scenarios and write them down.
For physical exam section – you are expected to explain the appropriate physical exam components that needs to be done with reference to the case study. You should mention the systems and include information on what you will be looking for in each system based on the information given in the case study .
For the diagnostic tests – You are expected to come up with appropriate diagnostic tests that pertains to the case study scenario and the differential diagnosis that you are required to come up with.
If you have five differential diagnosis include information from most likely diagnosis to lease likely diagnosis and explain why you chose those differential diagnosis and the diagnostic tests . Again all pertaining to the information given in the case study. It is like proving your case . Why and why not .
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