Chancre Episodic note case study


For this assignment, you will analyze an Episodic 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.


Review the following Episodic note case study:

Subjective:CC: “I have bumps on my bottom that I want to have checked out.”HPI: DJ, a 25-year-old white female 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 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.PMH: AsthmaMedications: Symbicort 160/4.5mcgAllergies: NKDAFH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERDSocial: 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 169lbsHeart: RRR, no murmursLungs: CTA, chest wall symmetricalGenital: 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 labiaAbd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, negMcBurneyDiagnostics: 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

  • Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
  • Based on the Episodic note case study:
    • Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.
    • Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
    • 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.

THE LAB ASSIGNMENT

Using evidence-based resources from your search, 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 three different references from current evidence-based literature.Rubric Detail Select Grid View or List View to change the rubric’s layout.Name: NURS_6512_Week_10_Assignment1_RubricExcellentGoodFairPoorWith regard to the SOAP note case study provided and using evidence-based resources from your search, 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.10 (10%) – 12 (12%)The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation.7 (7%) – 9 (9%)The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.4 (4%) – 6 (6%)The response vaguely analyzes the subjective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.0 (0%) – 3 (3%)The response inaccurately analyzes the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.· Analyze the objective portion of the note. List additional information that should be included in the documentation.10 (10%) – 12 (12%)The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation.7 (7%) – 9 (9%)The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation.4 (4%) – 6 (6%)The response vaguely analyzes the objective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.0 (0%) – 3 (3%)The response inaccurately analyzes the objective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.· Is the assessment supported by the subjective and objective information? Why or why not?14 (14%) – 16 (16%)The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.11 (11%) – 13 (13%)The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a clear explanation.8 (8%) – 10 (10%)The response vaguely identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation.0 (0%) – 7 (7%)The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.· What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?18 (18%) – 20 (20%)The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis.15 (15%) – 17 (17%)The response accurately describes appropriate diagnostic tests for the case and explains how the test results would be used to make a diagnosis.12 (12%) – 14 (14%)The response vaguely and/or with some inaccuracy describes appropriate diagnostic tests for the case and vaguely and/or with some inaccuracy explains how the test results would be used to make a diagnosis.0 (0%) – 11 (11%)The response inaccurately describes appropriate diagnostic tests for the case, with an inaccurate or missing explanation of how the test results would be used to make a diagnosis.· Would you reject or accept the current diagnosis? Why or why not?
    · Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.23 (23%) – 25 (25%)The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature.20 (20%) – 22 (22%)The response states whether to accept or reject the current diagnosis, with an accurate explanation of sound reasoning. The response accurately identifies three conditions as a differential diagnosis, with reasoning that is explained using three different references from current evidence-based literature.17 (17%) – 19 (19%)The response states whether to accept or reject the current diagnosis, with a vague explanation of the reasoning. The response identifies two to three conditions as a differential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three or fewer references from current evidence-based literature.0 (0%) – 16 (16%)The response inaccurately states or is missing a statement of whether to accept or reject the current diagnosis, with an explanation that is inaccurate and/or missing. The response identifies three or fewer conditions as a differential diagnosis, with reasoning that is missing or explained inaccurately using two or fewer references from current evidence-based literature.Written Expression and Formatting – Paragraph Development and Organization:
    Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.5 (5%) – 5 (5%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.4 (4%) – 4 (4%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.3 (3%) – 3 (3%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.0 (0%) – 2 (2%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.Written Expression and Formatting – English writing standards:
    Correct grammar, mechanics, and proper punctuation5 (5%) – 5 (5%)Uses correct grammar, spelling, and punctuation with no errors.4 (4%) – 4 (4%)Contains a few (1 or 2) grammar, spelling, and punctuation errors.3 (3%) – 3 (3%)Contains several (3 or 4) grammar, spelling, and punctuation errors.0 (0%) – 2 (2%)Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.5 (5%) – 5 (5%)Uses correct APA format with no errors.4 (4%) – 4 (4%)Contains a few (1 or 2) APA format errors.3 (3%) – 3 (3%)Contains several (3 or 4) APA format errors.0 (0%) – 2 (2%)Contains many (≥ 5) APA format errors.Total Points: 100
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