NURS 6512 Week 10 Assignment 1: Advanced Health Assessment and Diagnostic Reasoning: Lab Assignment

NURS 6512 Week 10 Assignment 1: Advanced Health Assessment and Diagnostic Reasoning: Lab Assignment

NURS 6512 Week 10 Assignment 1: Advanced Health Assessment and Diagnostic Reasoning: Lab Assignment

The patient in the provided case study is a 21-year-old female college student who presents to the clinic complaining of bumps on her genital area. She describes the bumps as painless and rough. She is sexually active with multiple partners. The patient denies abnormal vaginal discharge. She had her last Pap smear exam about 3 years back which revealed no dysplasia. She was diagnosed with chlamydia about 2 years ago, after which she completed her treatment. This paper aims at analyzing both the subjective and objective data to help identify additional information required to confirm the patient’s diagnosis.

BUY A CUSTOM PAPER HERE

Subjective Data

The subjective portion of the patient history lacks some relevant information required to promote an accurate diagnosis. In as much as the patient complains of bumps on her genital area, additional information such as onset, and progress of the bumps in terms of changes in color or size are missing. Regarding the sexual history of the patient, in addition to the patient reporting having multiple sex partners, it is important to state whether she engages in protected or unprotected sex with these partners (Golrokh Mofrad et al., 2021). Additional subject data that should be included in the patient history is immunization status and reproductive history comprising of use of birth control and menstrual cycle. The patient should also state whether she has been using any medication or ointment for the bumps.

Objective Date

            The objective portion of the patient history is quite substantial but still misses a few details essential in promoting patient diagnosis. The results of physical examination of the abdomen, genitalia, lungs, and heart have been well documented with vital signs. General examination results of the patient’s breast and lymphatics should also be included. The objective portion should also include an assessment of the vulva for atrophic changes (Mauskar et al., 2020). Finally, for the diagnostics, only an HSV specimen was obtained, leaving out crucial tests like urinalysis for UTI, chlamydia, and gonorrhea, and scraping test for spirochetes.

Assessment

            The assessment suggests that the patient has chancre, which is not entirely supported by both the subjective and objective information provided. A chancre is a painless ulcer of the genitals which usually occurs during the primary stage of syphilis (Golrokh Mofrad et al., 2021). The patient in the provided case study presents with pumps on her genital area which are painless, unlike in the case of chancre which is characterized by painful genital sores.

Diagnostics

            Given that the patient presents with bumps on her genital area, several lab tests need to be ordered given a large number of possible diagnoses. Such tests include HSV viral culture for lesion test to rule out HSV infection, nucleic acid amplification tests to find out whether the patient’s symptoms as a result of gonorrhea or chlamydia, and an acetic acid test to rule out spirochetes (O’Byrne & Orser, 2019). For a diagnosis of syphilis, a positive EIA test is required.

Diagnosis

            As mentioned earlier, I would reject the current diagnosis of a chancer. The patient reports painless bumps on her genital area which is quite different from chancre which is characterized by painful genital sores. Three possible differential diagnoses for the patient are vulvar ulcers, genital warts, and Herpes simplex II. Vulvar ulcer area condition of the female genitalia is characterized by an extremely painful or painless ulcer on the genital area as a result of an STI or other infections (Mauskar et al., 2020). The patient is provided a case study and presents with a history of chlamydia which might have contributed to this condition. Genital warts, on the other hand, areas also characterized by ulceration of the genital area for which the patient is positive (Sonnenberg et al., 2019). However, in most cases the ulcers are painful and a pap smear is needed to confirm this diagnosis. Finally, Herpes simplex II is also associated with small red or white bumps or blisters on the genital area (Golrokh Mofrad et al., 2021).

Conclusion

The provided patient history lacks substantial subjective and objective information required to make an accurate diagnosis. However, the provided information is direct towards vulvar ulcers as the primary diagnosis, as further diagnostic test results are needed to confirm this diagnosis.

References

Golrokh Mofrad, M., Sadigh, Z. A., Ainechi, S., & Faghihloo, E. (2021). Detection of human papillomavirus genotypes, herpes simplex, varicella-zoster, and cytomegalovirus in breast cancer patients. Virology Journal, 18(1), 1-10. https://doi.org/10.1186/s12985-021-01498-z

Mauskar, M. M., Marathe, K., Venkatesan, A., Schlosser, B. J., & Edwards, L. (2020). Vulvar diseases: conditions in adults and children. Journal of the American Academy of Dermatology, 82(6), 1287-1298. https://doi.org/10.1016/j.jaad.2019.10.077

O’Byrne, P., & Orser, L. (2019). Express testing for sexually transmitted infections: clinical results. Journal of Research in Nursing, 24(7), 541-547. https://doi.org/10.1177/1744987119843152

Sonnenberg, P., Tanton, C., Mesher, D., King, E., Beddows, S., Field, N., … & Johnson, A. M. (2019). Epidemiology of genital warts in the British population: implications for HPV vaccination programs. Sexually transmitted infections, 95(5), 386-390. http://dx.doi.org/10.1136/sextrans-2018-053786

ORDER A PLAGIARISM-FREE PAPER HERE

 

NURS 6512: Advanced Health Assessment and Diagnostic Reasoning: Week 10

***PLEASE DO NOT REWRITE THIS SOAP NOTE FOR YOUR ASSIGNMENT, NARRATIVE/PARAGRAPH, APA FORMAT ONLY.
The Lab Assignment
Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature. Narrative/Paragraphs only. DO NOT rewrite a SOAP note. Do narrative/paragraphs without making a LIST. Please answer ALL questions.
• 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.
• This is to be a NARRATIVE (PARAGRAPHS). Answer each question. PLEASE DO NOT submit anything other than the responses to the questions. You DO NOT need to submit a SOAP note.
Please submit a Paper with APA format.

Below is the Episodic SOAP Note

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 noted on external labia.
• Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, negMcBurney
• 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.

Use subheadings for the 5 Statements/questions. These are from the Rubric.
PLEASE DO NOT REWRITE THIS SOAP NOTE! It will lead to High Safe Assign Scores!
Utilize Safe Assign Drafts for originality report before final submission.
Utilize at least 3 scholarly , peer reviewed sources within 5 years.

 

Name: NURS_6512_Week_10_Assignment1_Rubric

	Excellent	Good	Fair	Poor
With regard to the SOAP note case study provided and 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.	Points Range: 10 (10.00%) – 12 (12.00%) The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation.	Points Range: 7 (7.00%) – 9 (9.00%) The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.	Points Range: 4 (4.00%) – 6 (6.00%) The response vaguely analyzes the subjective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.	Points Range: 0 (0.00%) – 3 (3.00%) The response inaccurately analyzes the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
·   Analyze the objective portion of the note. List additional information that should be included in the documentation.	Points Range: 10 (10.00%) – 12 (12.00%) The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation.	Points Range: 7 (7.00%) – 9 (9.00%) The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation.	Points Range: 4 (4.00%) – 6 (6.00%) The response vaguely analyzes the objective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.	Points Range: 0 (0.00%) – 3 (3.00%) The response inaccurately analyzes the objective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
·  Is the assessment supported by the subjective and objective information? Why or why not?	Points Range: 14 (14.00%) – 16 (16.00%) The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.	Points Range: 11 (11.00%) – 13 (13.00%) The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a clear explanation.	Points Range: 8 (8.00%) – 10 (10.00%) The response vaguely identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation.	Points Range: 0 (0.00%) – 7 (7.00%) The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.
·   What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?	Points Range: 18 (18.00%) – 20 (20.00%) The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis.	Points Range: 15 (15.00%) – 17 (17.00%) The response accurately describes appropriate diagnostic tests for the case and explains how the test results would be used to make a diagnosis.	Points Range: 12 (12.00%) – 14 (14.00%) The response vaguely and/or with some inaccuracy describes appropriate diagnostic tests for the case and vaguely and/or with some inaccuracy explains how the test results would be used to make a diagnosis.	Points Range: 0 (0.00%) – 11 (11.00%) The response inaccurately describes appropriate diagnostic tests for the case, with an inaccurate or missing explanation of how the test results would be used to make a diagnosis.
·   Would you reject or accept the current diagnosis? Why or why not? ·   Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.	Points Range: 23 (23.00%) – 25 (25.00%) The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature.	Points Range: 20 (20.00%) – 22 (22.00%) The response states whether to accept or reject the current diagnosis, with an accurate explanation of sound reasoning. The response accurately identifies three conditions as a differential diagnosis, with reasoning that is explained using three different references from current evidence-based literature.	Points Range: 17 (17.00%) – 19 (19.00%) The response states whether to accept or reject the current diagnosis, with a vague explanation of the reasoning. The response identifies two to three conditions as a differential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three or fewer references from current evidence-based literature.	Points Range: 0 (0.00%) – 16 (16.00%) The response inaccurately states or is missing a statement of whether to accept or reject the current diagnosis, with an explanation that is inaccurate and/or missing. The response identifies three or fewer conditions as a differential diagnosis, with reasoning that is missing or explained inaccurately using two or fewer references from current evidence-based literature.
Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.	Points Range: 5 (5.00%) – 5 (5.00%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.	Points Range: 4 (4.00%) – 4 (4.00%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.	Points Range: 3 (3.00%) – 3 (3.00%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.	Points Range: 0 (0.00%) – 2 (2.00%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation	Points Range: 5 (5.00%) – 5 (5.00%) Uses correct grammar, spelling, and punctuation with no errors.	Points Range: 4 (4.00%) – 4 (4.00%) Contains a few (1 or 2) grammar, spelling, and punctuation errors.	Points Range: 3 (3.00%) – 3 (3.00%) Contains several (3 or 4) grammar, spelling, and punctuation errors.	Points Range: 0 (0.00%) – 2 (2.00%) Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.	Points Range: 5 (5.00%) – 5 (5.00%) Uses correct APA format with no errors.	Points Range: 4 (4.00%) – 4 (4.00%) Contains a few (1 or 2) APA format errors.	Points Range: 3 (3.00%) – 3 (3.00%) Contains several (3 or 4) APA format errors.	Points Range: 0 (0.00%) – 2 (2.00%) Contains many (≥ 5) APA format errors.

Name:NURS_6512_Week_10_Assignment1_Rubric