In this Lab 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.
To Prepare
Review the Episodic note case study for this weeks Assignment.
Based on the Episodic note case study:
Review this weeks 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 patients condition. How would the results be used to make a diagnosis?
Identifyat least fivepossible 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.
Week10 Assignment: Special ExaminationsBreast, Genital,Prostate, and Rectal/Genitalia assessment
Subjective:
CC: I have bumps on my bottom that I want to have checked out.
HPI: AB, a 21-year-old WF college student reports to your clinic with externalbumps 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 thepast year. Her initial sexual contact occurred at age 18. She reports no abnormalvaginal discharge. She is unsure how long the bumps have been there butnoticed them about a week ago. Her last Pap smear exam was 3 years ago, andno dysplasia was found; the exam results were normal. She reports one sexuallytransmitted infection (chlamydia) about 2 years ago. She completed thetreatment for chlamydia as prescribed.
PMH: Asthma
Medications: Symbicort 160/4.5mcg
Allergies: NKDA
FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD
Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
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