Nursing LAB ASSIGNMENT: ASSESSING THE GENITALIA AND RECTUM question

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:

GENITALIA ASSESSMENT

Subjective:

· CC: dysuria and urinary frequency

· HPI: RG is a 30 year old female with increase urinary frequency and dysuria that began 3 days ago. 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

· LMP: N/A

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

Objective:

· 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

Assessment:

· UTI

· STD

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.