Health Assessment Essay Paper
Health Assessment Essay Paper
Subjective Data
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. Health Assessment Essay Paper
Subjective data entails the information obtained from the patient. It includes personal particulars, chief complaint, history of the presenting illness, past medical and surgical history, current medication, family history, personal and social-economic history, and review of systems.
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Patient particulars: initials-AB, age: 21 years, gender: female, race: white
CC: “I have bumps on my bottom that I want to have checked out.”
HPI: AB, a 21-year-old WF college student who reports to your clinic with external bumps on her genital area. She states the “bumps” are painless and feel rough. 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. Health Assessment Essay Paper
PMH: She is known to have asthma. She was previously admitted to the hospital due to chlamydia infection and severe urinary tract infection.
Medications: Symbicort 160/4.5mcg
Allergies: she is allergic to dust, cold weather, and fur.
FH: She is the firstborn in a family of four. Her siblings are alive and healthy. There is no positive history of breast or cervical cancer in the family. Her father is hypertensive and is on treatment. Her mother has hypertension and GERD follow-up at the national hospital.
Social: Denies tobacco use; occasional EtOH, married, 3 children (1 girl, 2 boys). She works as a barmaid at the local bar. Her marriage is not stable because they disagree with her husband most of the time and she ends up engaging in unprotected sexual intercourse with other men.
Review Of Systems
General: she denies a history of fever, weight loss, and persistent fatigue.
HEENT:
Eyes: she has no visual loss, blurred vision, double vision, or yellow sclera.
Ears, Nose, Throat: no hearing loss, sneezing, congestion, runny nose, or sore throat.
Skin: no rash or itching.
Cardiovascular denies chest pain, chest pressure or chest discomfort, or edema.
Respiratory: She denies cough or sputum, chest pain.
Gastrointestinal: denies having diarrhea and constipation, abdominal discomfort and cramping, incomplete emptying of the bowel, and unexplained weight loss.
Genitourinary: she reports of a burning sensation during urination. She has bump-like eruptions.
Neurological: no headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities, no change in bowel or bladder control.
Musculoskeletal: no muscle pain, back pain, joint pain, or stiffness.
Hematologic: no anemia, bleeding, or bruising.
Lymphatics: has enlarged nodes, no history of splenectomy.
Endocrinology: no reports of sweating, cold, or heat intolerance. No Polyuria or Polydipsia.
Reproductive: she denies Reports of vaginal discharge. she is sexually active and has genital warts. She has multiple sexual partners. She has three children, no history of miscarriage, and family planning use.
Allergies: Experiences an asthmatic attack when exposed to dust, cold weather, and fur.
Objective Data
Objective data is the information made from the clinician’s findings. It includes a general examination, vitals, systemic examination, and diagnostic investigations. For example, general examination for this patient; she is in a fair general condition, appropriately dressed for time and weather. She has no pallor, no cyanosis, no jaundice, no dehydration, and no edema.
Vitals: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs
Heart: RRR, SI S2 heard no murmurs. The pericardium is palpable at the 5th intercostal space mid-clavicular line. Health Assessment Essay Paper
Lungs: CTA, chest wall symmetrical, n mass, scars, and respiratory distress. The patient has a resonant percussion note and vesicular breath sounds.
Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. The perineum is intact. The vaginal mucosa pink and moist with rugae present. The pos for firm, round, small, painless ulcer noted on external labia. There are papular eruptions with a cauliflower form surrounding the perineum, vulva, and vaginal walls.
Abdominal Examination: The abdomen has a normal contour, no mass or therapeutic scars. There are no areas of tenderness or organ enlargement. There is a tympanic note on percussion and normal-active bowel sounds on auscultation. Rebound, Murphy’s, and McBurney signs are negative.
Diagnostics: HSV specimen obtained. This diagnostic test is not enough for this patient because from the subjective and objective data obtained from the patient has all the risk factors for the human papillomavirus. Therefore, I would do a rapid HIV test to rule out HIV infection. Pap smear and colposcopy are indicated to look for papillomatosis or rule out HPV infection. A biopsy is indicated for atypical lesions or inpatient with immunosuppression.
Assessment
I tend to disagree with this patient’s diagnosis because a chancre is a painless ulcer mostly formed during the primary stage of syphilis. Instead, the diagnosis is genital warts; they are painless bumps and pruritus as stated by the patient. Differential diagnoses for this patient are genital warts, condyloma lata, and herpes simplex. Genital wart is an epidermotrophic human papilloma that presents with multiple painless plague-like lesions which are hyper-pigmented (Dai, & Song, 2021). Condyloma lata is a sexually transmitted infection commonly known as secondary syphilis. It presents with a wart-like eruption at the genitalia caused by spirochete treponema pallidum (Yuan, et al, 2018). Herpes simplex is a sexually transmitted infection that presents with herpetic vesicles at the external genitalia, labia majora, labia minora, and introitus (Armangue, et al, 2018). The vesicles might rapture leaving tender ulcers.
CASE STUDY:
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 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.
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:
VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
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 labia. Health Assessment Essay Paper
Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, neg McBurney
Diagnostics: HSV specimen obtained
Assessment: Chancre
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.
RUBRIC
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Excellent 10 (10%) – 12 (12%)
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.
Good 7 (7%) – 9 (9%)
The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.
Fair 4 (4%) – 6 (6%)
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.
Poor 0 (0%) – 3 (3%)
The response inaccurately analyzes the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Excellent 10 (10%) – 12 (12%)
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.
Good 7 (7%) – 9 (9%)
The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation.
Fair 4 (4%) – 6 (6%)
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.
Poor 0 (0%) – 3 (3%)
The response inaccurately analyzes the objective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?
Excellent 14 (14%) – 16 (16%)
The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.
Good 11 (11%) – 13 (13%)
The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a clear explanation.
Fair 8 (8%) – 10 (10%)
The response vaguely identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation.
Poor 0 (0%) – 7 (7%)
The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.
What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis? Health Assessment Essay Paper
Excellent 18 (18%) – 20 (20%)
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.
Good 15 (15%) – 17 (17%)
The response accurately describes appropriate diagnostic tests for the case and explains how the test results would be used to make a diagnosis.
Fair 12 (12%) – 14 (14%)
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.
Poor 0 (0%) – 11 (11%)
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.
Would you reject or accept the current diagnosis? Why or why not?
Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
Excellent 23 (23%) – 25 (25%)
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 thoroughly using three or more different references from current evidence-based literature.
Good 20 (20%) – 22 (22%)
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 current evidence-based literature.
Fair 17 (17%) – 19 (19%)
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 current evidence-based literature.
Poor 0 (0%) – 16 (16%)
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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 reasoning that is missing or explained inaccurately using two or fewer references from current evidence-based literature.
Written Expression and Formatting – Paragraph Development and Organization: Health Assessment Essay Paper
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
Excellent 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
Good 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
Fair 3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.
Poor 0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
RESOURCES
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 17, “Breasts and Axillae”
Chapter 19, “Female Genitalia”
Chapter 20, “Male Genitalia”
Chapter 21, “Anus, Rectum, and Prostate”
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby. Health Assessment Essay Paper
https://class.content.laureate.net/1a2455018bb6e05f03ebba70dfca8222.pdf
https://class.content.laureate.net/8349b14d970285a83a97532ab5cf7ce8.pdf
https://class.content.laureate.net/8c913f6a06d80ac3bdfcbdde3361dafb.pdf
https://class.content.laureate.net/d5dcc2db965a84521d8f58e651f018e4.pdf
https://class.content.laureate.net/a4d1902572c7fc5c36f19e026fd3f5e4.pdf
https://class.content.laureate.net/c6c32b4479cd039969661af75cdd1899.pdf
https://www.cdc.gov/std/#
References
Armangue, T., Spatola, M., Vlagea, A., Mattozzi, S., Cárceles-Cordon, M., Martinez-Heras, E., … & Zabalza, A. (2018). Frequency, symptoms, risk factors, and outcomes of autoimmune encephalitis after herpes simplex encephalitis: a prospective observational study and retrospective analysis. The Lancet Neurology, 17(9), 760-772.
Dai, & Song, (2021). An unusual case of oral condyloma lata. International Journal of Infectious Diseases, 105, 349-350.
Yuan, J., Ni, G., Wang, T., Mounsey, K., Cavezza, S., Pan, X., & Liu, X. (2018). Genital warts treatment: beyond imiquimod. Human vaccines & immunotherapeutics, 14(7), 1815-1819. Health Assessment Essay Paper
