WK10Assgnlastnamefirstinitialextension.docx - BREAST ...

BREAST, GENITAL, PROSTATE, AND RECTAL 1
Breast, Genital, Prostate, and Rectal
Walden University
6512N & Advance Health Assessment
May 09, 2021

BREAST, GENITAL, PROSTATE, AND RECTAL 2
Breast, 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 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 reported 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

BREAST, GENITAL, PROSTATE, AND RECTAL 3
• Genital: Normal female hair pattern distribution; no masses or swelling. Urethral
meatus intact without erythema or discharge. The perineum is intact. Vaginal mucosa pink and
moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia
• Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, negMcBurney
Diagnostics: HSV specimen obtained
Assessment: Chancre
Analyze the subjective portion of the note. List additional information that should be
included in the documentation.
The subject data is limited, with many unanswered questions for the patient. The
practitioner has more questions and assessing the patient's GENERAL- No weight loss, fever,
chills, weakness, or fatigue. HEENT-headaches, sores in the mouth, trouble swallowing,
GENITOURINARY: Burning on urination? Pregnancy? Last menstrual period, MM/DD/YYYY
NEUROLOGICAL: headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling?Any
change in bowel or bladder control? MUSCULOSKELETAL: No muscle, back pain, joint pain,
or stiffness? HEMATOLOGIC: No anemia, bleeding, or bruising. LYMPHATICS: No enlarged
nodes. PSYCHIATRIC: No history of depression or anxiety? I would ask about risky behaviors
being she is married with 3 children. Did she infect her spouse? What is the spouse's STD
history? “ states she is sexually active and has had more than one partner during the past year.”
The patient also reported a “sexually transmitted infection (chlamydia) about 2 years ago” Her
initial sexual contact was at age 18 there is a strong association with sexually transmitted
infections (Epstein et al., 2014). Description used needs more information- Genital: Normal
female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema