To Prepare

• Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
• Based on the Episodic note case study:
  • 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.

Rubric Detail

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Name: NURS_6512_Week_10_Assignment_Rubric

		Excellent	Good	Fair	Poor
With 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.		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.	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.	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.	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.		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.	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.	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.	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?		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.	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.	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.	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?		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.	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.	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.	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 differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.		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.	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.	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.	0 (0%) – 16 (16%) 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: 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 (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.	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.	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.	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.
Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation		5 (5%) – 5 (5%) Uses correct grammar, spelling, and punctuation with no errors.	4 (4%) – 4 (4%) Contains a few (1 or 2) grammar, spelling, and punctuation errors.	3 (3%) – 3 (3%) Contains several (3 or 4) grammar, spelling, and punctuation errors.	0 (0%) – 2 (2%) Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written 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 (5%) – 5 (5%) Uses correct APA format with no errors.	4 (4%) – 4 (4%) Contains a few (1 or 2) APA format errors.	3 (3%) – 3 (3%) Contains several (3 or 4) APA format errors.	0 (0%) – 2 (2%) Contains many (≥ 5) APA format errors.
Total Points: 100

Name: NURS_6512_Week_10_Assignment_Rubric

By Day 7 of Week 10

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Expert Answer and Explanation

Assessing the Genitalia and Rectum

Information that should be included in the Subjective Data

The nurse in charge of the patient has included relevant information when assessing the patient subjectively. However, the patient failed to include the OTC medication used by the patient to reduce the symptoms of the condition. The nurse should have been more specific when highlighting the medicine; the patient was using. In the social history section, the patient could have mentioned the spirituality level of the patient. Information about spirituality can be used during the treatment plan. Vaccination and immunization information should have been included in the patient medical history. The patient should have been asked if she can remember what caused the bumps. This information can help the nurse determine the cause of the condition. Lastly, the nurse should have included information about when last the patient had sex.

Information that should be included in the Objective Data

The nurse has highlighted most of the information in the physical assessment. However, the caregiver has not the heart rate vital for the patient. Assessing the heart rate can help the patient determine the health of the patient’s heart. Also, the objective data should have explained whether the patient experiences nausea, vomiting, eye problem, hearing issues, and throat sickness. The patient’s psychiatric state should also be included in the objective data. In other words, the nurse should determine how the medical condition has affected him psychologically. Overall, the care provider has covered almost all data in this part.

Justification of the Assessment

The care provider responsible for the patient recommended Chancre as the disease affecting the patient. According to de Oliveira et al. (2020), Chancre is a genital ulcer that shows days after a patient has been infected by a bacterium known as Treponema pallidum, a germ that causes syphilis. The assessment is supported by subjective data. According to Donateli et al. (2019), Chancre is a painless disease. This information supported the patient when she said that she does not feel any pain. However, objective information does not support the assessment. The caregiver has not produced the results of the laboratory test, and this has made it hard to recommend the assessment based on objective information.

Importance of Diagnostics

Diagnostics will be so vital in this case because the patient has not given the caregiver adequate information to produce accurate information. The patient gave very few details to work with, and the physical examination did not provide any viable data. Thus, diagnostic information would be significant in this case in that it would be used to determine the actual disease ailing the patient. Donateli et al. (2019) mention that diagnostic results from the lad tests are more accurate and reliable than subjective assessment and physical examination. Also, the process would be vital when recommending medication for the patient.

Differential diagnoses

I would accept the current diagnosis because the patient does not feel any pain, and this is the key symptom of the mentioned disease. Another diagnosis for this case may be syphilis. According to Liu et al. (2017), syphilis can cause bumps in its primary stage. Another diagnosis may be chancroid. Chancroid can also cause ulcerated lesions on one’s genitals. Herpes can also be a diagnosis for the condition because it also causes a genital ulcer (Watts et al., 2016). The last disease that can cause ulcers is candidiasis.

References

de Oliveira, D., Rosa, L. D., Serrão, B. B. P., de Oliveira, J. B. R., da Paz, A. P. C., da Silva, R. D. S., … & dos Reis, H. L. B. (2020). Rollet’s mixed chancre in Brazilian pregnant women: An unusual case report. International Journal of Infectious Diseases, 91, 57-59. https://www.sciencedirect.com/science/article/pii/S1201971219304503

Donateli, L. R., Barbosa, B. P., Tosato, N. B., Jacomele, J. C., Oliveira, D. M., & Dos, H. R. (2019). Rollet’s mixed chancre in Brazilian pregnant women: An unusual case report. International journal of infectious diseases: IJID: official publication of the International Society for Infectious Diseases. https://europepmc.org/article/med/31743797

Liu, X. K., Wang, Z. S., & Li, J. (2017). Kissing chancre of primary syphilis. IDCases, 7, 38. doi: 10.1016/j.idcr.2016.12.004

Watts, P. J., Greenberg, H. L., & Khachemoune, A. (2016). Unusual primary syphilis: Presentation of a likely case with a review of the stages of acquired syphilis, its differential diagnoses, management, and current recommendations. International journal of dermatology, 55(7), 714-728. https://doi.org/10.1111/ijd.13206

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