Genitalia and Rectum Abnormal Findings

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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.

Genitalia and Rectum Abnormal Findings

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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