Health Assessment
11/2/23, 3:37 PM Topic: Week 10
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Week 10 Anita Simmons
All Sec�ons
Week 10
Great work last week! Coming up in week 10….
WRITE THIS OUT LIKE A PAPER IN PARAGRAPH FORMAT
Special Examinations—Breast, Genital, Prostate, and Rectal
GENITALIA ASSESSMENT
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
11/2/23, 3:37 PM Topic: Week 10
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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, negMcBurney
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This announcement is closed for comments
Diagnostics: HSV specimen obtained
Assessment: Chancre
PLAN: This section is not required for the assignments in this course (NURS 6512) but
will be required for future courses.
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.
YOU WILL NEED TO MAKE THE DATA UP TO FIT THE DIAGNOSIS!
DUE By Day 7 of Week 10
Almost through….finish strong!
Dr Simmons
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