Analyze An Episodic Note Case Study For This Assignment ✓ Solved

Analyze an Episodic Note Case Study That for This Assignment You Will Analyze An Episodic note case study that

For this 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. Please remember to pretend that this is an actual patient and give as much detail as possible!

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

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.

Sample Paper For Above instruction

Introduction

The clinical assessment of a patient presenting with genital lesions requires a thorough understanding of the patient's history, objective findings, and diagnostic tools. Accurately identifying the nature of the lesions, their duration, associated symptoms, and risk factors are essential steps in establishing a differential diagnosis and guiding appropriate management. This paper analyzes a case study involving a young woman with external genital bumps, focusing on subjective and objective data, differential diagnosis, and evidence-based decision-making regarding diagnostic testing and treatment.

Analysis of the Subjective Data

The subjective portion of the note provides critical information about the patient's chief complaint, medical history, sexual activity, and prior health screenings. However, additional details are necessary to improve diagnostic accuracy. For example, more comprehensive sexual history should include questions about the specific characteristics and progression of the bumps, associated symptoms such as pain, itching, or discharge, and any history of previous similar lesions. Inquiry about recent sexual contacts, condom use, and other risk factors such as new partners or unprotected sex is relevant for assessing STI risk.

Additional Subjective Information Recommendations

• Duration and progression of the genital bumps
• Presence of symptoms like pain, itching, or discharges
• History of similar lesions or previous genital infections
• Use of protection during sexual activity and number of partners
• Menstrual and obstetric history relevant to genital health

Objective Data Assessment

The objective section describes vital signs, general physical examination, and genital examination findings, notably, the presence of a firm, round, painless ulcer on the labia. Nonetheless, additional objective data can substantiate the clinical impression. For instance, a more detailed description of the lesion's size, number, borders, base, and any signs of inguinal lymphadenopathy would be valuable. Also, examining adjacent areas for additional lesions, dermatitis, or signs of inflammation can help differentiate between infectious and non-infectious causes.

Additional Objective Data Recommendations

• Precise measurement of the lesion(s)
• Description of lesion morphology, borders, and base
• Assessment of inguinal lymph nodes
• Photographic documentation for record keeping
• Vaginal exam findings, including discharge or other abnormalities

Correlating the Assessment with Collected Data

The current assessment—"chancre"—is consistent with the findings: a painless, firm ulcer on the external labia. The clinical presentation suggests a primary syphilitic lesion, especially given the painless nature and location. However, this diagnosis should be corroborated with diagnostic testing, considering other conditions that may mimic this presentation.

Diagnostic Testing and Its Role

Serologic testing for syphilis (e.g., RPR or VDRL test) is essential to confirm the diagnosis of a chancre caused by Treponema pallidum. Additionally, testing for herpes simplex virus (HSV) via PCR or culture could be considered, especially if the lesion characteristics change or if pain develops. Darkfield microscopy or direct fluorescent antibody testing from the lesion exudate can also provide rapid confirmation of syphilis. The results will confirm or exclude the presumptive diagnosis, guiding treatment and follow-up.

Diagnosis Evaluation

The initial diagnosis of syphilis (chancre) is supported by the painless, indurated ulcer and patient's sexual history. However, differential diagnoses should be considered to avoid misdiagnosis. The potential for false positives or co-infections necessitates confirmatory testing before finalizing the diagnosis.

Possible Differential Diagnoses

1. Herpes simplex virus (HSV) infection
2. Genital warts (condyloma acuminatum)
3. Genital molluscum contagiosum

Rationale for Differential Diagnoses

Herpes simplex typically presents with painful, recurrent vesicular lesions, but early primary lesions can sometimes be painless. Condyloma acuminatum presents as painless, papillomatous growths, while molluscum features small, umbilicated papules. Differentiating these conditions relies heavily on clinical features and diagnostic tests (Workowski & Bolan, 2015; Patel et al., 2017; Hook & Marra, 2017).

Conclusion

This case underscores the importance of comprehensive history-taking, detailed physical examinations, and appropriate testing in diagnosing genital lesions. Confirmatory diagnostics are necessary to distinguish between conditions with similar presentations, allowing for correct treatment and prevention strategies. An accurate differential diagnosis ensures optimal patient care and management.

References

• Workowski, K. A., & Bolan, G. A. (2015). Sexually transmitted diseases treatment guidelines, 2015. MMWR. Recommendations and reports, 64(RR-03), 1-137.
• Patel, N., et al. (2017). Evaluation and management of genital lesions. Journal of Clinical Medicine, 6(3), 25.
• Hook, E. W., & Marra, C. M. (2017). Acquired syphilis. New England Journal of Medicine, 376(8), 768-778.
• Stamm, L. V. (2018). Persistent and recurrent infections with herpes simplex virus. Herpesviridae, 9(1), 1-9.
• Hainer, B. L. (2015). Diagnosis and treatment of genital herpes simplex virus infections. American Family Physician, 91(8), 558-564.
• O'Farrell, N. (2014). Congenital syphilis. British Medical Bulletin, 24(1), 128-169.
• Miller, W. C., et al. (2016). Epidemiology of sexually transmitted infections. Journal of Infectious Diseases, 213(Suppl 2), S69-S75.
• Moore, P. S., & Schenkel, K. (2017). Approach to genital ulcers. Medical Clinics, 101(5), 855-865.
• Taneja, K., et al. (2019). Evidence-based review of genital ulcer diseases. Infectious Disease Clinics, 33(2), 391-408.
• Burgos, R., & Fernandez, C. (2020). Diagnostic strategies for genital ulcer disease. Infectious Disease Clinics, 34(4), 883-898.