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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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