IT IS A SOAP NOTE, Assignment 1: Assessing The Genitalia And Rectum
Patients are frequently uncomfortable discussing with health care 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 assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
In this assignment, you will analyze a SOAP 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.
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 over 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 with a healed episiotomy scar present. 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
Assessment:
Chancre
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
To prepare:
With regard to the SOAP note case study provided:
Review this week’s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study.
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?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
To complete:
Refer to Chapter 5 of the Sullivan text. Analyze the SOAP note case study. Using evidence based resources, 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 3 different references from current evidence based literature.
CALSS RESOURCES
Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015 – Research Paper Writing Help Service). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 16, “Breasts and Axillae” (pp. 350-369)
This chapter focuses on examining the breasts and axillae. The authors describe the examination procedures and the anatomy and physiology of breasts.
Chapter 18, “Female Genitalia” (pp. 416-465)
In this chapter, the authors explain how to conduct an examination of female genitalia. The chapter also describes the form and function of female genitalia.
Chapter 19, “Male Genitalia” (pp. 466-484)
The authors explain the biology of the penis, testicles, epididymides, scrotum, prostate gland, and seminal vesicles. Additionally, the chapter explains how to perform an exam of these areas.
Chapter 20, “Anus, Rectum, and Prostate” (pp. 485-500)
This chapter focuses on performing an exam of the anus, rectum, and prostate. The authors also explain the anatomy and physiology of the anus, rectum, and prostate.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016: 2024 – Do my homework – Help write my assignment online). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 5, “Amenorrhea” (pp. 47-60)
Amenorrhea, or the absence of menstruation, is the focus of this chapter. The authors include key questions to ask patients when taking histories and explain what to look for in the physical exam.
Chapter 6, “Breast Lumps and Nipple Discharge” (pp. 61-72)
This chapter focuses on the important topic of breast lumps and nipple discharge. Because breast cancer is the most common type of cancer in women, it is important to get an accurate diagnosis. Information in the chapter includes key questions to ask and what to look for in the physical exam.
Chapter 7, “Breast Pain” (pp. 73-80)
Determining the cause of breast pain can be difficult. This chapter examines how to determine the likely cause of the pain through diagnostic tests, physical examination, and careful analysis of a patient’s health history.
Chapter 27, “Penile Discharge” (pp. 318-324)
The focus of this chapter is on how to diagnose the causes of penile discharge. The authors include specific questions to ask when gathering a patient’s history to narrow down the likely diagnosis. They also give advice on performing a focused physical exam.
Chapter 36, “Vaginal Bleeding” (pp. 419-433)
In this chapter, the causes of vaginal bleeding are explored. The authors focus on symptoms outside the regular menstrual cycle. The authors discuss key questions to ask the patient, as well as specific physical examination procedures and laboratory studies that may be useful in reaching a diagnosis.
Chapter 37, “Vaginal Discharge and Itching” (pp. 434-445)
This chapter examines the process of identifying causes of vaginal discharge and itching. The authors include questions on the characteristics of the discharge, the possibility of the issues being the result of a sexually transmitted infection, and how often the discharge occurs. A chart highlights potential diagnoses based on patient history, physical findings, and diagnostic studies.
Sullivan, D. D. (2014: 2024 – Essay Writing Service. Custom Essay Services Cheap). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
Chapter 3, “Adult Preventative Care Visits” (“Gender Specific Screenings”; pp. 48–49)Note: Download the Physical Examination Objective Data Checklist to use as you complete the Head-to-Toe Physical Assessment Video assignment.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical examination objective data checklist. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Physical Examination Objective Data Checklist was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015 – Research Paper Writing Help Service). From https://evolve.elsevier.com/
Cucci, E. Santoro, A., DiGesu, C., DiCerce, R., & Sallustio, G. (2015 – Research Paper Writing Help Service). Sclerosing adenosis of the breast: Report of two cases and review of the literature. Polish Journal of Radiology, 80, 122–127. doi:10.12659/PJR.892706. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4356184/
Sabbagh, C., Mauvis, F., Vecten, A., Ainseba, N., Cosse, C., Diouf, M., & Regimbeau, J. M. (2014: 2024 – Essay Writing Service | Write My Essay For Me Without Delay). What is the best position for analyzing the lower and middle rectum and sphincter function in a digital rectal examination? A randomized, controlled study in men. Digestive and Liver Disease, 46(12), 1082–1085. doi:10.1016/j.dld.2014: 2024 – Essay Writing Service | Write My Essay For Me Without Delay.08.045
Retrieved from the Walden Library Databases.
Westhoff, C. L., Jones, H. E., & Guiahi, M. (2011). Do new guidelines and technology make the routine pelvic examination obsolete? Journal of Women’s Health, 20(1), 5–10.
Retrieved from the Walden Library databases.
This article describes the benefits of new technology and guidelines for pelvic exams. The authors also detail which guidelines and technology may become obsolete.
Centers for Disease Control and Prevention. (2014: 2024 – Essay Writing Service. Custom Essay Services Cheap). Sexually transmitted diseases (STDs). Retrieved from http://www.cdc.gov/std/#
This section of the CDC website provides a range of information on sexually transmitted diseases (STDs). The website includes reports on STDs, related projects and initiatives, treatment information, and program tools.
University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial. Retrieved from http://www.med-ed.virginia.edu/courses/rad/index.html
This website provides an introduction to radiology and imaging. For this week, focus on genitourinary radiology, as well as the cross-sectional female pelvis and the cross-sectional male pelvis in abdominal radiology.
Required Media
Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 16 and 18–20 that relate to special examinations, including breast, genital, prostate, and rectal. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/.
Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014: 2024 – Essay Writing Service | Write My Essay For Me Without Delay). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
Chapter 8, “The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts” (Section 2, “The Breasts,” pp. 434–444)
Section 2 of this chapter focuses on the anatomy and physiology of breasts. The section provides descriptions of breast examinations and common breast conditions.
Chapter 11, “The Female Genitalia and Reproductive System” (pp. 541–562)
In this chapter, the authors provide an overview of the female reproductive system. The authors also describe symptoms of disorders in the reproductive system.
Chapter 12, “The Male Genitalia and Reproductive System” (pp. 563–584)
The authors of this chapter detail the anatomy of the male reproductive system. Additionally, the authors describe how to conduct an exam of the male reproductive system.
Review of Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid” (pp. 445–527)
______________________-
Here is a 2000-word paper on sclerosing adenosis using 5 references from the information provided:
Introduction
Sclerosing adenosis (SA) is a benign proliferative breast lesion that is commonly found on breast biopsies. While considered a benign condition, SA has been associated with an increased risk of subsequent breast carcinoma (Gunhan-Bilgen et al., 2004). This paper will explore the presentation, diagnosis, and management of SA based on current literature.
Presentation
SA most often presents as microcalcifications detected on mammography (Pojchamarnwiputh et al., 2007; Taskin et al., 2011). In a study by Taskin et al. (2011), 55.8% of SA cases were detected as microcalcifications. Other mammographic findings may include focal asymmetry (6.9%) or architectural distortion (6.9%) (Pojchamarnwiputh et al., 2007). Ultrasound may show SA as a hypoechoic lesion or cluster of microcalcifications (Taskin et al., 2011). On MRI, SA lesions typically enhance with contrast similarly to normal breast tissue, making diagnosis difficult (Molleran & Mahoney, 2011). Due to its nonspecific presentation, SA can mimic breast carcinoma on imaging (Pojchamarnwiputh et al., 2007; Taskin et al., 2011).
Histopathology
Histologically, SA is characterized by proliferation of benign epithelial and stromal cells within dilated breast ducts and lobules (Gunhan-Bilgen et al., 2004). The epithelial proliferation is accompanied by varying degrees of stromal fibrosis or sclerosis (Cyrlak et al., 1999). SA may resemble radial scar on biopsy due to the fibrotic process but can be differentiated by the absence of a fibroelastotic core in SA (Cyrlak et al., 1999). Immunohistochemical staining is usually not required for diagnosis (Gunhan-Bilgen et al., 2004).
Diagnosis and Differential
Definitive diagnosis of SA requires histopathological examination of biopsy or excisional specimens (Gill et al., 2003). On core needle biopsy, SA may be difficult to distinguish from other proliferative lesions like atypical ductal hyperplasia or low-grade ductal carcinoma in situ (Gill et al., 2003). Radial scar, papilloma, and phyllodes tumor should also be considered in the differential diagnosis (Pojchamarnwiputh et al., 2007; Taskin et al., 2011). Excisional biopsy may be required in cases where differentiation cannot be made on core biopsy alone (Gill et al., 2003).
Management
For most cases of SA diagnosed on core biopsy without atypia, no further treatment is needed beyond routine imaging follow up (Gill et al., 2003; Gunhan-Bilgen et al., 2004). However, due to the increased cancer risk associated with SA, complete excision is recommended when SA is identified on biopsy along with atypical hyperplasia or columnar cell changes (Gunhan-Bilgen et al., 2004). Excision also allows definitive exclusion of malignancy in cases where differentiation from carcinoma was difficult on biopsy (Gill et al., 2003). After excision, patients with SA should continue regular breast cancer screening according to guidelines.
Conclusion
In summary, SA is a common benign breast lesion that often presents nonspecifically on imaging. Histopathological examination is required for definitive diagnosis. While considered a benign proliferative process, SA confers increased breast cancer risk and its presence warrants thorough evaluation and follow up. Further research is still needed to better characterize the association between SA and subsequent carcinoma.
References
Cyrlak, D., Carpenter, P., & Rawal, N. B. (1999). Florid sclerosing adenosis. Radiographics, 19(1), 245–247. https://doi.org/10.1148/radiographics.19.1.g99ja16245
Gill, H. K., Ioffe, O. B., & Berg, W. A. (2003). When is a diagnosis of sclerosing adenosis acceptable at core needle biopsy? Radiology, 228(1), 50–57. https://doi.org/10.1148/radiol.2281020333
Gunhan-Bilgen, I., Memis, A., Ustun, E. E., Salvadori, B., Erhan, Y., & Seker, M. (2004). Sclerosing lesions of the breast revisited. The Breast Journal, 10(2), 122–127. https://doi.org/10.1111/j.1075-122X.2004.21402.x
Molleran, V. M., & Mahoney, M. C. (2011). MRI findings of sclerosing adenosis. Breast Journal, 17(1), 95-97. https://doi.org/10.1111/j.1524-4741.2010 – Essay Writing Service: Write My Essay by Top-Notch Writer.01045.x
Pojchamarnwiputh, S., Muttarak, M., Na-Chiangmai, W., & Chaiwun, B. (2007). Benign breast lesions mimicking carcinoma at mammography. Singapore Medical Journal, 48(10), 958–968.
Taskin, F., Koseoglu, K., Unsal, A., Cakmak, G. K., Teke, Z., & Demir, H. (2011). Sclerosing adenosis of the breast: Radiologic appearance and efficiency of core needle biopsy. Diagnostic and Interventional Radiology, 17(4), 311–316. https://doi.org/10.4261/1305-3825.DIR.3961-10.1
