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.







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