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 casestudy that describes abnormal findings in patients seen in a clinicalsetting. You will consider what history should be collected from thepatients, as well as which physical exams and diagnostic tests shouldbe conducted. You will also formulate a differential diagnosis withseveral 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 clinicwith external bumps on her genital area. She states the bumps arepainless and feel rough. She states she is sexually active and has hadmore than one partner over the past year. Her initial sexual contactoccurred at age 18. She reports no abnormal vaginal discharge. She isunsure how long the bumps have been there but noticed them about a weekago. Her last Pap smear exam was 3 years ago, and no dysplasia wasfound; the exam results were normal. She reports one sexuallytransmitted infection (chlamydia) about 2 years ago. She completed thetreatment 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 orswelling. Urethral meatus intact without erythema or discharge.Perineum intact with a healed episiotomy scar present. Vaginal mucosapink and moist with rugae present, pos for firm, round, small, painlessulcer 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 beappropriate 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 notecase study. Using evidence based resources, answer the followingquestions and support your answers using current evidence from theliterature.

• 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 adifferential diagnosis for this patient. Explain your reasoning using atleast 3 different references from current evidence based literature.