Introduction
Nurse practitioners will be faced with a wide range of cases that require a reserve of
learning and mastery. Evaluating the genitalia and influencing a clinical conclusion when a
patient presents with amb
...
Introduction
Nurse practitioners will be faced with a wide range of cases that require a reserve of
learning and mastery. Evaluating the genitalia and influencing a clinical conclusion when a
patient presents with ambiguous subjective data can be difficult. Practitioners must be stellar
with correspondence and evaluation aptitudes that will give the objective information needed to
determine the appropriate diagnosis. This paper will dismember the subjective and the objective
information introduced and recommend extra data that should be incorporated into this area of
the SOAP note, as proved by references of current insightful literature. Also, current proof from
literature will be displayed, analytic tests that would be imperative to assess, as well as
subjective information from the patient will be recorded with references to either bolster or
disprove this evaluation. As medical professionals, analytic tests must be upheld with clinical
support about why it is relevant to the right diagnosis. At last, I will distinguish three conceivable
conclusions to consider and put forth my defense for accepting or dismissing every finding,
including the present diagnosis of choice.
Analysis of Subjective Data
In this segment I will investigate the subjective information for this situation. The
subjective information is as follows:
Chief Complaint (CC): "I have bumps on my bottom that I need to have looked
at."
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3
Assessing the Genitalia and Rectum
History of Present Illness (HPI): AB, a 21-year-old white female, undergraduate
student reports to the facility with outer bumps on her genital area. She expresses
the bumps are not painful and feel rough. She states she is sexually active and has
had in excess of one sexual partner over the previous year. Her underlying sexual
contact happened at age 18. She reports no unusual vaginal release. She is
uncertain to what extent the bumps have been there yet seen them about seven
days prior. Her last Pap smear exam was three years prior, and no dysplasia was
discovered; the exam results were ordinary. She reports one sexually transmitted
disease (chlamydia) around two years back. She finished the treatment for
chlamydia as endorsed.
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