Reproductive system and ethics

Reproductive system and ethics Reproductive system and ethics Format: Episodic/Focused SOAP Note Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. Chapter 18, “Female Genitalia” (pp. 416-465)In this chapter, the authors explain how to conduct an examination of female genitalia. The chapter also describes the form and function of female genitalia. Reproductive system and ethics Chapter 19, “Male Genitalia” (pp. 466-484)The authors explain the biology of the penis, testicles, epididymides, scrotum, prostate gland, and seminal vesicles. Additionally, the chapter explains how to perform an exam of these areas. Chapter 20, “Anus, Rectum, and Prostate” (pp. 485-500)This chapter focuses on performing an exam of the anus, rectum, and prostate. The authors also explain the anatomy and physiology of the anus, rectum, and prostate. Reproductive system and ethics A 21-year-old college student reports to your clinic with external bumps on her genital area. The bumps are painless and feel rough. The patient is sexually active and has had more than one partner over the past year. Her initial sexual contact occurred at age 18. The patient 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 had one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed. Reproductive system and ethics Consider what history would be necessary to collect from the patient in the case study you were assigned. 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. Post a description of the health history you would need to collect from the patient in the case study to which you were assigned. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. Example A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform? Reproductive system and ethics S. CC: “Knee pain” HPI: the patient is a 15 year old male who reports pain on both knees. The pain is described as being dull. Patient also states that at times he has clicking in one or both knees. The patient also describes a catching sensation under the patella. Patient with 5/10 pain at rest but pain elevated to 8/10 with movement. O: Alert and oriented X4, denies any numbness or tingling in extremities, no loss of sensation noted, positive pulses. BP-130/65, HR-101, RR-24, Temp.-98.1. Mother states the patient’s blood is out of norm for him. X-ray to be done in office. A: Differential diagnosis 1. Patellar tendonitis is a common overuse injury, caused by repeated stress on your patellar leading to injury to the tendon connecting your kneecap (patella) to your shinbone and pain is found in between that area. At first be present only as you begin physical activity or just after an intense workout. Reproductive system and ethics 2. Patellofemoral joint syndrome- Probable diagnosis- is one of the most common knee complaints of both the young active sportsperson and the elderly. Patients may report a painful catching sensation and a painful giving way of the knee and is mainly due to overuse or a change in exercise intensity 3. Osteoarthritis- Obesity in children and adolescents has been linked to musculoskeletal disorders and excess force or joint loading may lead to osteoarthritis in overweight teens. High-impact, high-intensity, and repetitive athletics have a strong association with the occurrence of osteoarthritis in teenagers. 4. Bursitis- Bursae reduce friction and cushion pressure points between your bones and the tendons, muscles and skin near your joints and when inflamed pain is felt with activity or rest. 5. Meniscus tear-The meniscus can tear with forceful twisting or rotation of the knee causing pain, swelling, and difficulty extending that extremity. Commonly associated with sports. P. -Use ice as needed for pain or inflammatory relief, especially following activity. Apply ice for 10-15 minutes, 4-6 times per day. This should be weaned off as progress permits. -Patient may have to modify his activity level by decreasing activities that increase pressure to the patellofemoral. Ergonomic postures may have to be taught. -Physical therapy to Increase muscle strength and increase flexibility. -Use a patellofemoral brace or McConnell taping as needed for activity. Reproductive system and ethics Analgesics such as acetaminophen as well as NSAIDs, should be utilized for consistent pain and weaned off. • To carry out any examination the doctor must have solid understanding of the knee anatomy. Some physical examinations include palpation, patellofemoral assessment, anterior drawer test and posterior drawer test. X-rays will help in finding out which part of the knee is abnormal or injured and therefore narrow down to specific health conditions Due to the fact that the knee has the biggest articulating surface and that it is the joint that bears the largest weight, it is therefore no surprise that it is the most vulnerable joint to injuries. Most knee pains are caused by musculoskeletal injuries from chronic overuse or acute trauma, or both; and commonly occur in active and/or athletic adults and teenagers. Reproductive system and ethics More often experiencing pain in the knees could be as a result of physical injury or exhaustion. Also, knee pain can be a symptom of a serious health condition. To be able to categorically diagnose the condition the practitioner will have to run some historical check on the patient before proceeding. Health history will be useful. In this case, the doctor might want to know if the patient is involved in any sporting activities and if he wears protective pads. This information is usually very invaluable in the diagnosis of knee pains particularly in young athletes. Also, the practitioner will look at the medical history to establish if the patient has been diagnosed with rheumatoid arthritis, pseudo gout, gout or any other joint disease. Finally, the practitioner will be interested in knowing if the patient has had any physical injuries or surgeries to the knees. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. Halabchi, F., Mazaheri, R., & Seif-Barghi, T. (2013, February 12). Patellofemoral Pain Syndrome and Modifiable Intrinsic Risk Factors; How to Assess and Address? Retrieved October 18, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC36907… Mayo Clinic. (2015, January 08). Patellar tendinitis, also known as jumper’s knee. Retrieved October 18, 2017, from https://www.mayoclinic.org/diseases-conditions/pat… Physiopedia. (n.d.). Osteoarthritis in young people. Retrieved October 18, 2017, from https://www.physio-pedia.com/Osteoarthritis_in_you… DISCUSSION 2 Ethical Concerns- As an advanced practice nurse, you will run into situations where a patient’s wishes about his or her health conflict with evidence, your own experience, or a family’s wishes. This may create an ethical dilemma. What do you do when these situations occur?In this Discussion, you will explore evidence-based practice guidelines and ethical considerations for specific scenarios. Scenario 1: The parents of a 5-year-old boy have accompanied their son for his required physical examination before starting kindergarten. His parents are opposed to him receiving any vaccines. Scenario 2: A 49-year-old woman with advanced stage cancer has been admitted to the emergency room with cardiac arrest. Her husband and one of her children accompanied the ambulance. Scenario 3: A 27-year-old man with Crohn’s disease has been admitted to the emergency room with an extreme flare-up of his condition. He explains that he has not been able to afford his medications for the last few months and is concerned about the costs he may incur for treatment. Scenario 4: A single mother has accompanied her two daughters, aged 15 and 13, to a women’s health clinic and has requested that the girls receive a pelvic examination and be put on birth control. The girls have consented to the exam but seem unsettled. Scenario 5: A 17-year-old boy has come in for a check-up after a head injury during a football game. He has indicated that he would like to be able to play in the next game, which is in 3 days. Scenario 6: A 12-year-old girl has come in for a routine check-up and has not yet received the HPV vaccine. Her family is very religious and believes that the vaccine would encourage premarital sexual activity. Scenario 7: A 57-year-old man who was diagnosed with motor neuron disease 2 years ago is experiencing a rapid decline in his condition. He prefers to be admitted to the in-patient unit at a hospice to receive end-of-life care, but his wife wants him to remain at home. To prepare: Select three scenarios, and reflect on the material presented throughout this course. What necessary information would need to be obtained about the patient through health assessments and diagnostic tests? Consider how you would respond as an advanced practice nurse. Review evidence-based practice guidelines and ethical considerations applicable to the scenarios you selected. By Day 3 Post the explanation of the health assessment information required for a diagnosis of your selected patients (include the scenario numbers). Explain how you would respond to the scenario as an advanced practice nurse using evidence-based practice guidelines and applying ethical considerations. Justify your responses. episodic_focused_soap_note_template.doc usw1_nurs_6512_episodicsoapexemplar.doc ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS Episodic/Focused SOAP Note Template Patient Information: Initials, Age, Sex, Race S. CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”. HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example: Location: head Onset: 3 days ago Character: pounding, pressure around the eyes and temples Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia Timing: after being on the computer all day at work Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better Severity: 7/10 pain scale Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance). PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system. Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. Example of Complete ROS: GENERAL: No weight loss, fever, chills, weakness or fatigue. HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, cough or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY. NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No 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. Reproductive system and ethics No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES: No history of asthma, hives, eczema or rhinitis. O. Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc. Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines) A. Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines. P. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. References You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting. Example Focused SOAP Note for a patient with chest pain S. CC: “Chest pain” HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms. PMH: Positive history of GERD and hypertension is controlled FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature cardiovascular disease in first degree relatives. SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years ROS General–Negative for fevers, chills, fatigue Cardiovascular–Negative for orthopnea, PND, positive for intermittent lower extremity edema Gastrointestinal–Positive for nausea without vomiting; negative for diarrhea, abdominal pain Pulmonary–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis O. VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70” General–Pt appears diaphoretic and anxious Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the second right inter-costal space which radiates to the neck. A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted. Gastrointestinal–The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; a bruit is heard in the right para-umbilical area. No masses or splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation. Pulmonary– Lungs are clear to auscultation and percussion bilaterally Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines) A. Differential Diagnosis: 1) Myocardial Infarction (provide supportive documentation with evidence based guidelines). 2) Angina (provide supportive documentation with evidence based guidelines). 3) Costochondritis (provide supportive documentation with evidence based guidelines). Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction © 2014 Laureate Education, Inc. Page 1 of 2 P. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. © 2014 Laureate Education, Inc. 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