Abnormal findings in patients seen in a clinical setting
Analyze an Episodic note case study given below 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.
SEE SAMPLER/EXAMPLE PAPER UPLOADED
Episodic Note Case Study
Wk10: Special Examinations—Breast, Genital, Prostate, and Rectal Genitalia ASSESSMENT
•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.
•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)
•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
The Lab Assignment Proper
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 4 different references from current evidence-based literature.
Assessing the Genitalia and Rectum
Various forms of sexually transmitted infections can cause skin alterations to the rectum and genitalia. Family nurse practitioners are required to knowledge that pays attention to preventive and holistic care of patients and this would encompass diagnosis and treatment of sexually transmitted infections. Correct diagnosis of abnormalities in the regions around rectum and genital require a well amassed set of skills in evaluation, as well as, understanding a healthy and unhealthy person. Therefore, this paper examines the SOAP note provided in a bid to determine additional information needed to accurate diagnosis based on the subjective and objective information provided by the client. The paper also states the diagnostics that would be necessary for diagnosing the vulvar skin impairment that the patient experiences. Further, it seeks to describe the differential diagnoses and explains whether or not I would reject or accept chancre as the most appropriate diagnosis.
Analysis of Subjective Portion of the SOAP Note
Subjective data is critical to an evaluation as the objective data. Subjective data as contended by Ball, Dains, Flynn, Solomon and Stewart (2015) encompasses precise things that patient with regards to what they experience and they include perceptions, feelings, as well as, concerns. The advanced practice nurse should gain the maximum degree of important subjective data so that it can be combined with objective data from physical assessment to design a more holistic evaluation of the patient experiences. Personally, I would wish to dig deeper into the patient’s sexual lifestyle and inquire on whether she has recently engaged in sexual intercourse with another person apart from her husband. Essentially, this question would be examined carefully and without any biases.
Based on the subjective data provided in the SOAP, a critical question that should be posed to the patient entails the number of sexual partners she has had. Clearly, the client has admitted that in the past year, she had engaged in sexual intercourse with more than one partner. However, this does not offer health practitioner the chance to clearly understand the patient’s sexual lifestyle that has played a major role towards her potential sexually transmitted disease. More than a single partner could imply that the patient could have engaged in sexual intercourse with more than ten people. The information provided regarding the number of people is indefinite. Therefore, a precise number is critical to appropriately establish the patient’s risk for contracting sexually transmitted disease.
Prudently, there is need to ask the patient on whether her sexual encounters are homosexual or heterosexual as this could enable the healthcare provider to clearly understand the possible diagnoses for the patient. Similarly, the patient should be requested to expound on the kind of sexual activity she engages in. This could create feelings of discomfort while gathering data for the assessment. While the patient has clearly mentioned that she is married, it would be important to inquire on whether she is a monogamous with her husband. In case she is not monogamous with her husband, she is subjecting her life and that of her husband at a risk of contracting STIs. The additional information I would ask the patient relates to the last time she was screened for STIs and whether she uses barrier techniques for controlling birth.
Objective Data Analysis
The objective part of the SOAP note lacks a detailed assessment of systems that would be critical for the most critical diagnosis. Any kind of infection or disease process will have a considerable impact on other body symptoms in various ways (Dains, Baumann & Scheibel, 2018).
Whether the Assessment Is Supported By Objective or Subjective Data
Intuitively, the objective and subjective data provided by the SOAP note herein not only support the diagnosis of chancre but address the concern of identifying the bacteria, virus, as well as, other infectious material that resulted in the growth of chancre. Nonetheless, more differential diagnoses are required to establish the cause of this form of chancre.
Whether Diagnostics Be Appropriate For This Case
Besides focusing on the genital, additional physical examinations should be done based on the present complaints that the patient raises. The painless ulcers noted from the client imply various infections but additional information is required to be precise in the differential diagnosis. Physical assessments such as breast assessment and well as, lymph nodes among others are missing. Precisely, HSV specimen was the only gathered diagnostic test. This is not sufficient to make accurate and logical diagnosis. Therefore diagnostics will be appropriate for this case and some of the diagnostic tests needed include culture and urinalysis and CBC with differential among others. Intuitively, DNA testing can assist in diagnosing herpes, chlamydia, syphilis, as well as, acetic acid test. However, each of these tests as maintained have extra test for sensitivity and positive isolation (de Carvalho, Nóbrega, Rodrigues, Almeida, de Mello Abdalla, & Nichiata, 2013).
Possible Differential Diagnosis
Chancre: This condition is a possible differential diagnosis for the patient because it symptoms resemble those depicted by the client. Essentially, chancre presents an open sore in regions around genitals and can in both males and females (Dains, Baumann, & Scheibel, 2018). At times, the condition can produce fluids that are highly contagious and can spread easily during sexual contact. As indicated in the case scenario provided, the patient reveals that she has been experiencing bumps; a symptom similar to chancre in which females suffering from this condition are likely develop several bumps on or areas around the labia. Diagnosing this condition entails taking the fluid sample collected from the chance lesion. Presently, there is no blood test that can be performed to diagnose a chance. Nonetheless, the physical assessment, as well as, history can help the physician to diagnose this condition. Prudently, the physician should examine the lymph nodes of the groin.
Genital Warts: genital warts are regions that usually develop around anus and genitals (Ball et al., 2015). The warts are usually caused by certain forms of human papillomavirus (HPV). This condition is regarded as possible differential diagnosis for the patient under the study because it symptoms resemble some that are manifested by the client. Some of the symptoms of this condition include whitish bumps, skin colored or whitish bumps visible on areas around penis, vagina, or penis. Dains, Baumann and Scheibel (2018) noted that warts may occur as one or in multiples. From the information provided in the case scenario, I do not believe that the patient suffers from genital warts since the bumps she describes are painless. Cocchio et al., (2017) maintained that genital warts are usually scratchy and cause a burning sensation in regions around anus or vagina.
Genital Herpes: in most occasions, women end up not detecting that they suffer from genital herpes since in most cases there are no symptoms that would indicate that the condition is a genital herpes. Genital herpes entails a fluid filled blister found on penis, labia or vagina (Dains, Baumann, & Scheibel, 2018). Genital herpes is regarded as a possible differential diagnosis for the patient under the study because those suffering from the condition may experience, burning, headache, tingling and swollen glands; conditions manifested by the patient under the study. Nonetheless, based on the information that the patient provided, I do not believe that the symptoms described herein are linked to genital herpes.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2018). Advanced Health Assessment & Clinical Diagnosis in Primary Care E-Book. Elsevier Health Sciences.
de Carvalho, P. M. G., Nóbrega, B. S. M., Rodrigues, J. L., Almeida, R. O., de Mello Abdalla, F. T., & Nichiata, L. Y. I. (2013). Prevention of sexually transmitted diseases by homosexual and bisexual women: a descriptive study. Online Brazilian journal of nursing, 12(4), 931-941.
Riaz, A., & Wei, G. (2017). Chancre of Primary Syphilis. Journal of Education and Teaching in Emergency Medicine, 2(4).