HPI AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area.
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Breast Genital Prostate And Rectal
Episodic note Case Study : Special Examinations—Breast, Genital, Prostate, and Rectal
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 state: s 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.
Insert your name and surname in the space provided above, as well as in the file name. Save the file as: First name Surname Assignment 4 – e.g. Lilly Smith Assignment 4. NB: Please ensure that you use the name that appears in your student profile on the Online Campus.
• 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.
Assignment: Assessing the Genitalia and Rectum
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.
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