For this 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. Please remember to pretend that this is an actual patient and gives as much detail as possible!

Week 10: Special Examinations—Breast, Genital, Prostate, and Rectal 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 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. 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, negMcBurney •

Diagnostics: HSV specimen obtained

Assessment: • Chancre

 

Patients are frequently uncomfortable discussing with healthcare professional’s 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 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.

To Prepare

• Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your 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.

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.

ZERO PLAGIARISM

FIVE REFERENCES NOT MORE THAN FIVE YEARS

PLEASE PAY ATTENTION TO THE CASE STUDY ON THE TOP

 ADMISSION HISTORY AND PHYSICAL

Patient Name: Jonathan Jones                                                                                        MR#: 44579

Attending Physician: Ajay Shah, M.D.                                                                    DOB: 12/24/89

Chief Complaint: 27 yo [year old] male presents with 2 days of worsening right lower quadrant belly pain, nausea, and vomiting.

History of Present Illness (HPI): 2 days prior to admission, the patient began complaining of diffuse belly pain that initially felt like indigestion. Over the course of the day, this pain grew progressively worse, localizing in the right lower quadrant. This pain became constant and dull and radiated to the back. The evening prior to admission the patient was awakened by pain and nausea. He drank some Alka-Seltzer and attempted to return to sleep, shortly after which he began vomiting nonbloody or bilious emesis. Shortly thereafter, the patient decided to come to the ED [Emergency Department].

The patient indicates he did have a fever but did not take his temperature. He denies chills, testicular pain, blood in the stool, or recent weight change. The patient’s last bowel movement was yesterday, with some small amounts of mucus but otherwise normal. He notes a history of irritable bowel syndrome. However, he states that this pain is different than the pain he has had in the past.

Past Medical History (PMH): Irritable bowel syndrome, last exacerbation 6 months ago. The rest of the past medical history is unremarkable.

Past Surgical History (PSH): Tonsillectomy and adenoidectomy in early childhood. Umbilical hernia repair at age 4.

Medications: None.

Allergies: NKDA

Social History: The patient is employed as a computer programmer. He is married and has no children. He has a 10-year pack-history (in this case, 5 years, two packs a day) of smoking. He drinks alcohol rarely.

Family History: Both parents are alive and well. One sister has a history of GERD.

Review of Systems: 12-point review of systems was performed and was negative except for those items noted in the HPI above.

Physical Examination

General: The patient is an alert and oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78. Pulse 68 and regular. Temperature 38.56°C (101.4°F).

HEENT: Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears clear. Throat normal.

Neck: The neck is supple with no carotid bruits.

Lungs: The lungs are clear to auscultation and percussion.

Heart: RRR, no m/g/r.

Abdomen: Nondistended. Bowel sounds are normal. There is rebound tenderness on the left side, with discomfort and guarding upon palpation in the right lower quadrant, and positive psoas sign [pain on extension of right thigh with patient lying on left side].

Extremities: No clubbing, cyanosis, or edema, distal extremities warm and well perfused.

Laboratory Data: Hemoglobin 14.6, hematocrit 43.6, WBC 13,000, sodium 138, potassium 3.8, chloride 105, CO2 24, BUN 10, creatinine 0.9, glucose 102. Urinalysis was negative.

Diagnostic Studies: Flat plate and upright films of the abdomen revealed a diffuse small bowel distension with no evidence of free air in the abdomen. CT of the abdomen indicated a thickened cecal wall and dilated appendix.

Assessment/Impression: 27 yo male with PMH significant for irritable bowel syndrome presents with clinical signs of acute onset appendicitis.

Plan: The patient will be admitted and kept NPO, and a laparoscopic appendectomy will be performed in the morning.

Rogers, M.D.

Admission H and P performed and dictated by Dr. Ajay Shah for Dr. Rogers.

Discussion Questions

1. Why is it important that the admitting doctor record information about the patient’s heart, lungs, and other body systems when the pain is in the patient’s abdomen?
2. How would you find out what the abbreviation HEENT means? What are some of the other abbreviations used in this case study, and what do they mean?
3. Using what you’ve learned about word parts, describe the types of surgeries listed in the patient’s past surgical history.
4. The extremities are described as “No clubbing, cyanosis, or edema.” Edema is explained in this chapter. Look up what the other two terms mean.

Your answers need to be typed as complete sentences and be thorough and detailed for full credit.