analyze an Episodic note case study given below 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.
SEE SAMPLER/EXAMPLE PAPER UPLOADED
Episodic Note Case Study
Wk10: Special ExaminationsâBreast, Genital, Prostate, and Rectal Genitalia ASSESSMENT
Subjective:
â¢CC: âI have bumps on my bottom that I want to have checked out.â
â¢HPI: AB, a 21-year-old WF 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.
â¢PMH: Asthma
â¢Medications: Symbicort 160/4.5mcg
â¢Allergies: NKDAâ¢FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD
â¢Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
â¢VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5â10â; WT 169lbs
â¢Heart: RRR, no murmurs
â¢Lungs: CTA, chest wall symmetrical
â¢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 labiaâ¢
Abd: soft, normoactive bowel sounds, neg rebound, neg murphyâs, neg McBurney
â¢Diagnostics: HSV specimen obtained
Assessment: Chancre
The Lab Assignment Proper
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 4 different references from current evidence-based literature.
Sample Solution
K. Rowling is the author of the Harry Potter series of fantasy novels. Rowling was born in London in 1965. She lived with her parents and her sister. Her family was not rich. She was a quiet child and she did not get her education in a special school. When she was on the train in 1990 traveling to London she got the great idea of a boy who was studying in a school for wizards. In December the same year her mother died of suffering from multiple sclerosis. At the same time she was writing the first novel of Harry Potter. She didnât tell her mother about it. Her death affected Rowlingâs writing because she wrote a lot of details about Harryâs own loss in the first book because she knew the feeling of loss so deeply. She married for the first time in 1992, and in 1993 she had her first child Jessica. But on 17 November she and her husband divorced. Rowling finished her manuscript in 1995 with an old manual typewriter. She submitted this book to many publishing houses and they rejected it. Then after one year the editor Barry Cunningham who works at Bloomsbury publishing house in London accepted the book and published 1000 copies in 1997. The book won the first award and then won the second award of the Childrenâs Book of the Year. After that, six more Harry Potter books were published. In 2004 Rowling became the richest person in the world. The Story of the novel Harry Potter is a ten year old boy. He is an orphan who lives with the Dursley family: his aunt Petunia, loathsome uncle Vernon, and his cousin Dudley. The Dursley family doesnât like Harry. One day Harry finds a letter sent to him. Before he opens the letter, uncle Vernon takes it. Then the letters come again later in huge numbers. But Vernon tears them all up. Finally he tries to escape from this letters to a miserable shack on a small island. On Harryâs birthday, a giant man named Hagrid tells Harry that he is a wizard and that he has been accepted at Hogwarts School of Witchcraft and Wizardry. He also tells him that his parents have been killed by Voldemort. He has a scar in his forehead during the battle. When he goes to the school, the students are assigned to four houses: Gryffindor, Ravenclaw, Slytherin and Hufflepuff. Harry is in Gryffindor. He becomes friends with Ron and Hermione. His enemy is Draco Malfoy (Slytherin). Then Harry becomes a member of the Quidditch team because he is skillful in flying on a bro>
K. Rowling is the author of the Harry Potter series of fantasy novels. Rowling was born in London in 1965. She lived with her parents and her sister. Her family was not rich. She was a quiet child and she did not get her education in a special school. When she was on the train in 1990 traveling to London she got the great idea of a boy who was studying in a school for wizards. In December the same year her mother died of suffering from multiple sclerosis. At the same time she was writing the first novel of Harry Potter. She didnât tell her mother about it. Her death affected Rowlingâs writing because she wrote a lot of details about Harryâs own loss in the first book because she knew the feeling of loss so deeply. She married for the first time in 1992, and in 1993 she had her first child Jessica. But on 17 November she and her husband divorced. Rowling finished her manuscript in 1995 with an old manual typewriter. She submitted this book to many publishing houses and they rejected it. Then after one year the editor Barry Cunningham who works at Bloomsbury publishing house in London accepted the book and published 1000 copies in 1997. The book won the first award and then won the second award of the Childrenâs Book of the Year. After that, six more Harry Potter books were published. In 2004 Rowling became the richest person in the world. The Story of the novel Harry Potter is a ten year old boy. He is an orphan who lives with the Dursley family: his aunt Petunia, loathsome uncle Vernon, and his cousin Dudley. The Dursley family doesnât like Harry. One day Harry finds a letter sent to him. Before he opens the letter, uncle Vernon takes it. Then the letters come again later in huge numbers. But Vernon tears them all up. Finally he tries to escape from this letters to a miserable shack on a small island. On Harryâs birthday, a giant man named Hagrid tells Harry that he is a wizard and that he has been accepted at Hogwarts School of Witchcraft and Wizardry. He also tells him that his parents have been killed by Voldemort. He has a scar in his forehead during the battle. When he goes to the school, the students are assigned to four houses: Gryffindor, Ravenclaw, Slytherin and Hufflepuff. Harry is in Gryffindor. He becomes friends with Ron and Hermione. His enemy is Draco Malfoy (Slytherin). Then Harry becomes a member of the Quidditch team because he is skillful in flying on a bro>
