1. Patients are frequently uncomfortable discussing with
healthcare professional’s issues that involve the genitalia and
rectum; however, gathering an adequate history and properly
conducting a physical exam are vital. Examining case studies of
genital and rectal abnormalities can help prepare advanced
practice nurses to accurately assess patients with problems in
these areas.
In this Lab Assignment, you will analyze an Episodic note case
study 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.
To Prepare
· 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.
Case Study Assignment
This week you will be reviewing another SOAP note and
reflecting on the additional information that you would be
needing. This is not in SOAP format, you will use
headings for each section, and give me dialogue on what
information is missing in each section. You will provide 5
differentials and reflect on the questions posed for the
assignment. Be sure to support with scholarly references.

2. 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 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

3. noted on external labia•Abd: soft, normoactive bowel sounds,
neg rebound, neg murphy’s, neg McBurney•Diagnostics: HSV
specimen obtained
Assessment: •Chancre
In summary, be sure to follow the rubric for this assignment.
Tell me what is missing in each section…..and would you
support or refute the diagnosis. Support that answer with
rationale, and provide differential diagnosis with supported
rationale. Utilize scholarly references to support your
rationales. Remember....if you are doing a focused exam, which
is what these case studies are.....be sure to really expand on the
body systems that you are concerned about to hone in on your
differential diagnosis. This will help you with your
documentation completeness going forward.
· Based on the Episodic note case study:
o 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.
o Search the Walden library or the Internet for evidence-based
resources to support your answers to the questions provided.
o Consider what history would be necessary to collect from the
patient in the case study.
o 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?
o Identify
at least five

4. 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.