This week you will look at
Evaluate abnormal findings on the genitalia and rectum
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the breasts, genitalia, prostate, and rectum
This week you will have an analysis of a SOAP note. It is important to remember that this is not to be in SOAP note format. This should be a narrative paper.
Here is the case that you will base this on:
CC:dysuria and urinary frequency
HPI:RG is a 30 year old female with increase urinary frequency and dysuria that . Pain is intermittent and described a burning only in urination, but c/o flank pain since last night. Reports intermittent chills and fever. Used Tylenol for pain with no relief. She rates her pain 6/10 on urination. Reports a similar episode 3 years ago.
PMH:UTI 3 years ago
PSHx:Hysterectomy at 25 years
Medication:Tylenol 1000 mg PO every 6 hours for pain
FHx:Mother breast cancer ( alive) Father hypertension (alive)
Social:Single, no tobacco , works as a bartender, positive for ETOH
Allergies:PCN and Sulfa
Review of Symptoms:
General:Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
Abdominal:Denies nausea and vomiting. No appetite
VS:Temp 100.9; BP: 136/80; RR 18; HT 6.0; WT 135lbs
Abdominal:Bowel sounds present x 4. Palpation pain in both lower quadrants. CVA tenderness
Diagnostics:Urine specimen collected, STD testing
PLAN:This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Review the Episodic note case study your instructor provides you for this weeks 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 weeks 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 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 patients condition. How would the results be used to make a diagnosis?
Identifyat least fivepossible 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 five different references from .
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