Patients are frequently uncomfortable discussing with healthcare professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital. Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to accurately assess patients with problems in these areas.
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.
RESOURCES I | ||||
Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources.
WEEKLY RESOURCES (httpsiwaldenuinstructure.com/courses/92247/modules/items/3096515)
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 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
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
- Analyze the objective portion of the note. List additional information that should be included in the
- 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.
BY DAY 7 OF WEEK 10
Submit your Assignment.
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With 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.
- 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?
12 to >9.0 pts Excellent
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.
12 to >9.0 pts Excellent
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.
16 to >13.0 pts Excellent
The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or
9 to >6.0 pts Good
The response accurately analyzes the subjective portion of the SOAP note and lists
additional information to be included in the documentation.
9 to >6.0 pts Good
The response accurately analyzes the objective portion of the SOAP note and lists
additional information to be included in the documentation.
13 to >10.0 pts Good
The response accurately identifies whether or not the assessment is supported by the subjective and/or
6 to >3.0 pts Fair
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.
6 to >3.0 pts Fair
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.
i
10 to >7.0 pts Fair
|
20 to >17.0 pts Excellent
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.
25 to >22.0 pts Excellent
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
17 to >14.0 pts Good
The response accurately describes appropriate diagnostic tests for the case and explains how the test results would be used to make a diagnosis.
22 to >19.0 pts Good
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
14 to >11.0 pts Fair
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.
19 to >16.0 pts Fair
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
11 to >0 pts Poor
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.
16 to >0 pts Poor
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
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