Assessing the Genitalia and Rectum

Please note this is an analysis of a soap note. Please make sure to go directly by the grading rubric. Do not deviate from the grading rubric! Please answer all requirements of the grading rubric.

Genitourinary Assessment

CC: Increased frequency and pain with urination

HPI:

T.S. is a 32-year-old woman who reports that for the past two days, she has dysuria, frequency, and urgency. Has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months.

Medical History:

None

Surgical History:

• Tonsillectomy in 2001
• Appendectomy in 2020

Review of Systems:

• General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
• Abdominal: Denies nausea and vomiting. No appetite

Objective

VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.

Pelvic Exam:

• mild tenderness to palpation in the suprapubic area
• bimanual pelvic examination reveals a normal-sized uterus and adnexae
• no adnexal tenderness.
• No vaginal discharge is noted.
• The cervix appears normal.
• Diagnostics: Urinalysis,
• STI

testing, Papsmear

Assessment:

• UTI

STI

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 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.

CriteriaRatingsPts

This criterion is linked to a Learning OutcomeWith 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.

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.

3 to >0 pts

Poor

The response inaccurately analyzes the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.

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.

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.

12 pts

This criterion is linked to a Learning Outcome Analyze the objective portion of the note. List additional information that should 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.

3 to >0 pts Poor

The response inaccurately analyzes the objective portion of the SOAP note, with inaccurate and/or missing additional information 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.

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.

12 pts

This criterion is linked to a Learning Outcome Is the assessment supported by the subjective and objective information? Why or why not?

16 to >13.0 pts

Excellent

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.

7 to >0 pts

Poor

The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.

13 to >10.0 pts Good The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a clear explanation.

10 to >7.0 pts Fair The response vaguely identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation.

16 pts

This criterion is linked to a Learning Outcome What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?

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.

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.

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.

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.

20 pts

This criterion is linked to a Learning Outcome 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.

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 thoroughly using three or more different references from current evidence-based literature.

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 reasoning that is missing or explained inaccurately using two or fewer references from current evidence-based literature.

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 current evidence-based literature.

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 current evidence-based literature.

2

5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: 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.

5 to >4.0 pts

Excellent

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.

2 to >0 pts

Poor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

4 to >3.0 pts Good 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.

3 to >2.0 pts Fair 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.

5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

5 to >4.0 pts Excellent

Uses correct grammar, spelling, and punctuation with no errors.

2 to >0 pts Poor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

4 to >3.0 pts Good Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3 to >2.0 pts Fair Contains several (3 or 4) grammar, spelling, and punctuation errors.

5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.

5 to >4.0 pts Excellent

Uses correct APA format with no errors.

2 to >0 pts Poor

Contains many (≥ 5) APA format errors.

4 to >3.0 pts Good Contains a few (1 or 2) APA format errors.

3 to >2.0 pts Fair Contains several (3 or 4) APA format errors.

5 pts

Total Points: 100