Case Analysis: GENITALIA ASSESSMENT 1
Case Analysis: Genitalia Assessment
[Author Name(s), First M. Last, Omit Titles and Degrees]
[Institutional Affiliation(s)]
, GENITALIA ASSESSMENT 2
Subjective
In the assessment of the lesion the mnemonic OLD CARTS could have been useful, the
nurse should have asked if this was the first time she noticed the bumps and if she had received
treatment beforehand, a recent history of fever or illness could also provide information for the
medical history and if anyone in her house had lice or scabies, the presence of bumps elsewhere
in the body, like the internal aspect of the legs and the characteristics of the lesions, such as if
they ulcer or crust, if they remain unchanged or if they spread, if the bumps are always present or
if they wax and wane and if she had tried using ointments or other medications to help them
improve.
Assessing past medical history could have also discussed the presence of any skin
condition, such as eczema. Her past reproductive history needs to be taken carefully and
thoroughly, confirm the number of sexual partners that she may have had during the last year, it
is important to ask about protection methods if used and confirmation of the no known drug or
food allergies. The bumps should also prompt for a review of systems, such as changes in weight
or if the patient has felt more fatigued than usual and alterations of her GU systems, such as
increased frequency or pain with urination or a history of dyspareunia, the presence or absence of
blood or discharge.
Objective
In the exploration of the GU system the cervix could have been explored for presence or
absence of cervical tenderness, a pap smear could also be an option since it’s been over three
years from the last one, the note doesn’t give information about tenderness or lymphadenopathy,
Case Analysis: Genitalia Assessment
[Author Name(s), First M. Last, Omit Titles and Degrees]
[Institutional Affiliation(s)]
, GENITALIA ASSESSMENT 2
Subjective
In the assessment of the lesion the mnemonic OLD CARTS could have been useful, the
nurse should have asked if this was the first time she noticed the bumps and if she had received
treatment beforehand, a recent history of fever or illness could also provide information for the
medical history and if anyone in her house had lice or scabies, the presence of bumps elsewhere
in the body, like the internal aspect of the legs and the characteristics of the lesions, such as if
they ulcer or crust, if they remain unchanged or if they spread, if the bumps are always present or
if they wax and wane and if she had tried using ointments or other medications to help them
improve.
Assessing past medical history could have also discussed the presence of any skin
condition, such as eczema. Her past reproductive history needs to be taken carefully and
thoroughly, confirm the number of sexual partners that she may have had during the last year, it
is important to ask about protection methods if used and confirmation of the no known drug or
food allergies. The bumps should also prompt for a review of systems, such as changes in weight
or if the patient has felt more fatigued than usual and alterations of her GU systems, such as
increased frequency or pain with urination or a history of dyspareunia, the presence or absence of
blood or discharge.
Objective
In the exploration of the GU system the cervix could have been explored for presence or
absence of cervical tenderness, a pap smear could also be an option since it’s been over three
years from the last one, the note doesn’t give information about tenderness or lymphadenopathy,
