Health Care > EXAM > NURS 6512 Week 10 Assignment: Assessing the Genitalia and Rectum (All)

NURS 6512 Week 10 Assignment: Assessing the Genitalia and Rectum

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NURS 6512 Week 10 Assignment: Assessing the Genitalia and Rectum .Episodic/Focused SOAP Note Template Patient Information: JW Age: 21 Sex: Female Race: Caucasian S. CC(chief complaint)... “I have bumps on my bottom that I want to have checked out. ” HPI: This 21-year-old Caucasian female presents to our clinic complaining of painless, rough bumps on her genital region. The onset of these bumps was approximately one week ago. JW reports being sexually active with more than one partner over the past year. She also has a history of chlamydia 2 years ago with completed treatments. She reports being sexually active since the age of 18 years of age. Current Medications: Symbicort 160/4.5mcg PO twice daily Allergies: NKDA PMHx: Chlamydia, Asthma Soc Hx: Denies tobacco use; occasional ETOH, married, 3 children (1 girl, 2 boys) Fam Hx: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD ROS: Example of Complete ROS: GENERAL: Denies weight loss, fever, chills, weakness or fatigue. HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat. SKIN: Reports bumps on around genital region, no vaginal discharge reported. CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. Denies palpitations or edema. RESPIRATORY: Denies shortness of breath, cough or sputum. GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. GENITOURINARY: Denies urinary symptoms. LMP: 03/22/18. Last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. Denies change in bowel or bladder control. MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness. HEMATOLOGIC: Denies anemia, bleeding or bruising. LYMPHATICS: Denies enlarged nodes. No history of splenectomy. PSYCHIATRIC: Denies history of depression or anxiety. ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia. [Show More]

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