SOAP NOTE ASSIGNMENTS NURS 6512

Assignment 1: Assessing the Genitalia and Rectum

Patients are frequently uncomfortable discussing with health care 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. SOAP Note Assignments

In this assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

In this assignment, you will analyze a SOAP 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.

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 over 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. SOAP Note Assignments
• 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 with a healed episiotomy scar present. 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, neg McBurney
• Diagnostics: HSV specimen obtained

Assessment:

• Chancre
• PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.SOAP Note Assignments

To prepare:

With regard to the SOAP note case study provided:

• Review this week’s Learning Resources, and consider the insights they provide about the case study.
• 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 patient.

To complete:

Refer to Chapter 5 of the Sullivan text. Analyze the SOAP note case study.  Using evidence based resources, answer the following questions and support your answers using current evidence from the literature.SOAP Note Assignments

• 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?SOAP Note Assignments
• 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 3 different references from current evidence based literature.

SOAP NOTE ASSIGNMENTS Rubric Detail

Select Grid View or List View to change the rubric’s layout.

Name: NURS_6512_Week_10_Assignment1_Rubric

• Grid View
• List View

		Excellent	Good	Fair	Poor
Quality of Work Submitted: The extent of which work meets the assigned criteria and work reflects graduate level critical and analytic thinking.		27 (27%) – 30 (30%)Assignment exceeds expectations. All topics are addressed with a minimum of 75% containing exceptional breadth and depth about each of the assignment topics.SOAP Note Assignments	24 (24%) – 26 (26%)Assignment meets expectations. All topics are addressed with a minimum of 50% containing good breadth and depth about each of the assignment topics.	21 (21%) – 23 (23%)Assignment meets most of the expectations. One required topic is either not addressed or inadequately addressed.	0 (0%) – 20 (20%)Assignment superficially meets some of the expectations. Two or more required topics are either not addressed or inadequately addressed.
Assimilation and Synthesis of Ideas: The extent to which the work reflects the student’s ability to:Understand and interpret the assignment’s key concepts.		27 (27%) – 30 (30%)Demonstrates the ability to critically appraise and intellectually explore key concepts.	24 (24%) – 26 (26%)Demonstrates a clear understanding of key concepts.	21 (21%) – 23 (23%)Shows some degree of understanding of key concepts.	0 (0%) – 20 (20%)Shows a lack of understanding of key concepts, deviates from topics.
Assimilation and Synthesis of Ideas: The extent to which the work reflects the student’s ability to:Apply and integrate material in course resources (i.e. video, required readings, and textbook) and credible outside resources.		18 (18%) – 20 (20%)Demonstrates and applies exceptional support of major points and integrates 2 or more credible outside sources, in addition to 2-3 course resources to support point of view.	16 (16%) – 17 (17%)Integrates specific information from 1 credible outside resource and 2-3 course resources to support major points and point of view.SOAP Note Assignments	14 (14%) – 15 (15%)Minimally includes and integrates specific information from 2-3 resources to support major points and point of view.	0 (0%) – 13 (13%)Includes and integrates specific information from 0 to 1 resource to support major points and point of view.
Written Expression and FormattingParagraph/ Sentence Structure: Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are clearly structured and carefully focused–neither long and rambling nor short and lacking substance.		9 (9%) – 10 (10%)Paragraphs/ Sentences follow writing standards for structure, flow, continuity and clarity.SOAP Note Assignments	8 (8%) – 8 (8%)Paragraphs/ sentences follow writing standards for structure, flow, continuity and clarity 80% of the time.	7 (7%) – 7 (7%)Paragraphs/ sentences follow writing standards for structure, flow, continuity and clarity 60%- 79% of the time.	0 (0%) – 6 (6%)Paragraphs/ sentences follow writing standards for structure, flow, continuity and clarity < 60% of the time.
Written Expression and FormattingEnglish writing standards: Correct grammar, mechanics, and proper punctuation.		5 (5%) – 5 (5%)Uses correct grammar, spelling, and punctuation with no errors.	3 (3%) – 4 (4%)Contains a few (1-2) grammar, spelling, and punctuation errors.	2 (2%) – 2 (2%)Contains several (3-4) grammar, spelling, and punctuation errors.	0 (0%) – 1 (1%)Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and FormattingThe assignment follows parenthetical/in-text citations, and at least 3 evidenced based references are listed.		5 (5%) – 5 (5%)Contains parenthetical/in-text citations and at least 3 evidenced based references are listed. SOAP NOTE ASSIGNMENTS	3 (3%) – 4 (4%)Contains parenthetical/ in-text citations and at least 2 evidenced based references are listed	2 (2%) – 2 (2%)Contains parenthetical/ in-text citations and at least 1 evidenced based reference is listed	0 (0%) – 1 (1%)Contains no parenthetical/in-text citations and 0 evidenced based references listed.
Total Points: 100

Name: NURS_6512_Week_10_Assignment1_Rubric.SOAP Note Assignments