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.

Description

GENITALIA ASSESSMENT case study

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, neg McBurney

Diagnostics: HSV specimen obtained

Assessment:

Chancre

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.

Read

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

Chapter 3, “SOAP Notes” (Previously read in Week 8)

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