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.
- 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?
CASE STUDY: see page below for question, see a another page for sample explanation.
CC: chief complains about Increased frequency and pain with urination
HPI: history of present illness
T.S. is a 32-year-old woman who reports that for the past two days, she has had 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 had a new partner for the past 3 months.
- 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
VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.
- mild tenderness to palpation in the suprapubic area
- bimanual pelvic examination reveals a normal-sized uterus and adnexa
- no adnexal tenderness.
- No vaginal discharge is noted.
- The cervix appears normal.
Diagnostics: Urinalysis, STI testing, Pap smear
- UTI-urinary tract infection
- STI-sexually transmitted infection
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
The Lab Assignment- On another page, I have attached a sample explanation to help you understand what this assignment is asking for and I have also added a grading rubric.
Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature within the last five years.
Pls, APA intact citation and each answer headings.
- Analyze the subjective portion of the note. List additional information that should be included in the documentation. Subjective is what patient reports
- Analyze the objective portion of the note. List additional information that should be included in the documentation. The objective is the assessment the provider observed
- Is the assessment supported by 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 a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.