Homework answers / question archive / Assignment: Lab Assignment: Assessing the Genitalia and Rectum Photo Credit: Getty Images Patients are frequently uncomfortable discussing with health care professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital

Assignment: Lab Assignment: Assessing the Genitalia and Rectum Photo Credit: Getty Images Patients are frequently uncomfortable discussing with health care professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital

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Assignment: Lab Assignment: Assessing the Genitalia and Rectum

Photo Credit: Getty Images

Patients are frequently uncomfortable discussing with health care 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.
• Comprehensive SOAP Template Patient Initials: _______ Age: _______ Gender: _______ Note: The mnemonic below is included for your reference and should be removed before the submission of your final note. O = onset of symptom (acute/gradual) L= location D= duration (recent/chronic) C= character A= associated symptoms/aggravating factors R= relieving factors T= treatments previously tried – response? Why discontinued? S= severity SUBJECTIVE DATA: Include what the patient tells you, but organize the information. Chief Complaint (CC): In just a few words, explain why the patient came to the clinic. History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom: 1. Location 2. Quality 3. Quantity or severity 4. Timing, including onset, duration, and frequency 5. Setting in which it occurs 6. Factors that have aggravated or relieved the symptom 7. Associated manifestations Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency. Allergies: Include specific reactions to medications, foods, insects, and environmental factors. Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors. Past Surgical History (PSH): Include dates, indications, and types of operations. © 2019 Walden University Page 1 of 3 Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function. Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits. Immunization History: Include last Tdp, Flu, pneumonia, etc. Significant Family History: Include history of parents, Grandparents, siblings, and children. Lifestyle: Include cultural factors, economic factors, safety, and support systems. Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text. General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here. HEENT: Neck: Breasts: Respiratory: Cardiovascular/Peripheral Vascular: Gastrointestinal: Genitourinary: Musculoskeletal: Psychiatric: Neurological: Skin: Include rashes, lumps, sores, itching, dryness, changes, etc. Hematologic: Endocrine: Allergic/Immunologic: OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see. Physical Exam: Vital signs: Include vital signs, ht, wt, and BMI. © 2019 Walden University Page 2 of 3 General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things. HEENT: Neck: Chest/Lungs: Always include this in your PE. Heart/Peripheral Vascular: Always include the heart in your PE. Abdomen: Genital/Rectal: Musculoskeletal: Neurological: Skin: ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan. PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses. Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines. Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines. Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines. REFLECTION: Reflect on your clinical experience and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence? © 2019 Walden University Page 3 of 3 Episodic/Focused SOAP Note Template Patient Information: Initials, Age, Sex, Race S. CC (chief complaint) a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example: Location: head Onset: 3 days ago Character: pounding, pressure around the eyes and temples Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia Timing: after being on the computer all day at work Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better Severity: 7/10 pain scale Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance). PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous © 2019 Walden University Page 1 of 3 and current use), any other pertinent data. Always add some health promo question here - such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system. Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. Example of Complete ROS: GENERAL: No weight loss, fever, chills, weakness or fatigue. HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, cough or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY. NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness. HEMATOLOGIC: No anemia, bleeding or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES: No history of asthma, hives, eczema or rhinitis. © 2019 Walden University Page 2 of 3 O. Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc. Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines) A. Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines. P. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. References You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting. © 2019 Walden University Page 3 of 3 Episodic/Focused SOAP Note Exemplar Focused SOAP Note for a patient with chest pain S. CC: “Chest pain” HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms. PMH: Positive history of GERD and hypertension is controlled FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature cardiovascular disease in first degree relatives. SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years ROS General--Negative for fevers, chills, fatigue Cardiovascular--Negative for orthopnea, PND, positive for intermittent lower extremity edema Gastrointestinal--Positive for nausea without vomiting; negative for diarrhea, abdominal pain Pulmonary--Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis O. VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70” General--Pt appears diaphoretic and anxious Cardiovascular--PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the second right inter-costal space which radiates to the neck. A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted. Gastrointestinal--The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; a bruit is heard in the right para-umbilical area. No masses or splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation. Pulmonary-- Lungs are clear to auscultation and percussion bilaterally Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines) A. Differential Diagnosis: 1) Myocardial Infarction (provide supportive documentation with evidence based guidelines). 2) Angina (provide supportive documentation with evidence based guidelines). 3) Costochondritis (provide supportive documentation with evidence based guidelines). Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction © 2019 Walden University Page 1 of 2 P. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. © 2019 Walden University Page 2 of 2