NURS 6512 Lab Assignment Assessing the Genitalia and Rectum

Walden University NURS 6512 Lab Assignment Assessing the Genitalia and Rectum-Step-By-Step Guide

This guide will demonstrate how to complete the Walden University NURS 6512 Lab Assignment Assessing the Genitalia and Rectum assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for NURS 6512 Lab Assignment Assessing the Genitalia and Rectum

Whether one passes or fails an academic assignment such as the Walden University NURS 6512 Lab Assignment Assessing the Genitalia and Rectum depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for NURS 6512 Lab Assignment Assessing the Genitalia and Rectum

The introduction for the Walden University NURS 6512 Lab Assignment Assessing the Genitalia and Rectum is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for NURS 6512 Lab Assignment Assessing the Genitalia and Rectum

After the introduction, move into the main part of the NURS 6512 Lab Assignment Assessing the Genitalia and Rectum assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for NURS 6512 Lab Assignment Assessing the Genitalia and Rectum

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for NURS 6512 Lab Assignment Assessing the Genitalia and Rectum

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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NURS 6512 Lab Assignment Assessing the Genitalia and Rectum

Lab Assignment Assessing the Genitalia and Rectum

The SOAP note concerns a 32-year-old woman who presents with chief complaints of increased frequency and dysuria. She has experienced pain with urination, urinary frequency, and urgency in the past two days. The patient is sexually active and has had a new sexual partner in the last three months. Physical exam findings include mild tenderness in the suprapubic area. The purpose of this assignment is to examine the SOAP note and discuss possible diagnoses.

Subjective Portion

The HPI should describe the urine if it is copious, foul-smelling, or have streaks of blood. The associated symptoms should also be included like fever, chills, malaise, or lower abdominal discomfort (AlShuhayb et al., 2022). Besides, information on contraceptive use needs to be included and should include the type of contraceptive the patient uses, duration of use, and associated side effects. The treatment used to manage the previous urinary symptoms should also be provided in the HPI. The subjective portion should have included current medications, allergies, immunization history, family history, and social history. Furthermore, the ROS should have included the pertinent positives and negatives in the respiratory and cardiovascular system, which should be assessed in every focused exam. It should also have included the genitourinary system since the patient has urinary symptoms.

Assessment of the Rectum and Genitalia

Patient Information:

Initials: AB Age: 21 Years Old Sex: Female Race: White S. CC (chief complaint): “I have bumps on my bottom that I want to have checked out.” HPI: AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner during the past year. Her initial sexual contact occurred at age 18. She 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 reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed. Location: genital area. Onset: Unsure of how long the pumps have been there but she noticed the about a week ago Character: Painless and feel rough Associated signs and symptoms: the pumps are reported to be pain and feels rough on touch. There are no associated symptoms such as itchiness and pain. Timing: None Exacerbating/ relieving factors: Unspecified Severity: The pumps do not have any symptoms such as pain or itchiness. Rating on pain therefore not applicable. Current Medications: Symbicort 160/4.5mcg Allergies: No known drug, food, or environmental allergies. PMHx: The client has history of asthma. She also has a history of sexually transmitted infection (chlamydia) over 2 years ago. She completed chlamydia treatment. Soc Hx: The patient is a college student, who reports to be sexually active and have had more than one partner in the last year. The initial sexual contact of the client was when she was 18. The client also denied tobacco use, occasional use of etoh, married, 3 children (1 girl, 2 boys). Fam Hx: No history of breast or cervical cancer, Father history of HTN, Mother has history of HTN and GERD

OBJECTIVE:

Physical exam:

Vital Signs: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs CV: Regular heart rhythm with no murmurs Lungs: CTA, chest wall symmetrical Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia. ABD: soft, normoactive bowel sounds, neg rebound, neg murphy’s, negMcBurney Diagnostic: HSV specimen obtained

Analysis of Additional Subjective Information Top of Form

The nurse should focus on obtaining additional subjective data from the patient besides those in the case snapshot. The additional subjective data will guide the development of accurate diagnosis and treatment plan for the client. The nurse should obtain the information about additional symptoms that are associated with the external pumps on her genitalia. The nurse should obtain information such as size, shape, any discharge, or changes in the pumps that might have occurred over the past in terms of appearance. The nurse should also obtain additional information about any history of similar pumps in the past. A history of closely related pumps of the genital area could guide the development of diagnoses such as warts in the patient. There is also the need for the nurse to obtain information related to medication use by the patient. A history of medication use such as those used in managing the pumps could aid in determining the cause of the problem (Stephen & Skillen, 2020). History on medication use could also guide the determination of whether the pumps are attributable to side effects or adverse reactions to a drug. The nurse should also obtain information about the use of any irritants in the past that might have caused the pump. For example, information about the types of soaps that the patient uses should be obtained. The client should also be asked about her sexual preferences. This will provide information about her sexual habits, which might have led to the development of the pumps. The effect of the pumps on the self-perception of the client should also be obtained. The nurse should try to rate the effect of the pumps on her self-image and self-esteem using an appropriate rating scale (Forbes & Watt, 2020). The additional subjective data that may be needed include history of skin problems such as eczema, menstrual history, and occupational history to determine any risk factors in her workplace place.

Analysis of Additional Objective information

Additional objective data should also be obtained from the client to increase the accuracy of the

NURS 6512 Lab Assignment Assessing the Genitalia and Rectum

diagnosis. The nurse should have performed rectal examination. The examination could have provided clues such as the presence of hemorrhoids or anal fissures. The nurse should have also provided information about the general appearance of the client. The general appearance could have provided clues on the social, emotional and physical impact of the pumps on the client. The nurse should have also performed head to toe examination of the client. The examination could have included the assessment of the skin to determine the existence of undetected skin lesions. The nurse should have also examined the oral cavity for any lesions, neck for inflamed lymph nodes and neck rigidity. The nurse should have also assessed the chest for any abnormal findings such as appearance, shape, or palpitations on auscultation (Cox, 2019). The above information could have guided the accuracy of the diagnoses made by the nurse.

Is this Assessment Supported by the Subjective and Objective Assessment?

The assessment is supported by subjective and objective data. Subjective data is the data that the patient provides concerning her experience with the health problem. The information is based on the perceived experiences by the patient and the management of the health problem. Subjective data provides the basis of assessment and physical examinations of the patient. The examples of subjective data that support the assessment include the client’s complaints, history of the complains, history of any vaginal discharge, her Pap smear examinations, and any significant past medical, surgical and family history. Objective data on the other hand is the data that the nurse obtains using assessment and physical examination techniques. The data is not based on the subjective experiences of the patient with the disease but the physiological changes in the patient due to the disease. Objective data is used to validate the subjective data (Perry et al., 2021). The examples of objective data in the case study include vital signs, auscultation of the heart and lungs and the observation of the genitalia. The diagnostic investigations that were ordered also form part of the objective data.

Appropriate Diagnostic Tests

The development of accurate diagnosis of the client’s problem can be achieved by performing a number of diagnostic investigations. One of them is skin scrap. A scrap of the pumps can be obtained for laboratory examination. The other investigation is tzank smear to test for herpes simplex. The client should be tested for syphilis using diagnostics such as Darkfield microscopy or enzyme immunoassay (Perry et al., 2021).

Current Diagnosis

The current diagnosis of chancre is accurate. Patients with chancre present with symptoms similar to those of the client in the case study. For example, the ulcers are asymptomatic and can last for a period of up to six weeks (Cox, 2019).

Differential Diagnosis

One of the differential diagnoses that should be considered for the patient in the case study is contact dermatitis. Contact dermatitis is a skin condition that is characterized by symptoms such as the presence of rashes, which are dry, scaly and cracked. It is however the least likely due to the absence of itchiness and oozing or crusting of the rashes. The second differential diagnosis is syphilis. The client has a history of multiple sexual partners, which predisposes her to syphilis. Patients with syphilis also show skin rashes such as chancre in the early stages of syphilis. The last differential diagnosis is herpes simplex. Patients with herpes simplex may have symptoms such as rashes in the genitals (Perry et al., 2021). However, it is least unlikely for the patient due to the lack of symptoms such as lymphadenopathy and fever.

Conclusion

The diagnosis of chancre in the case study is accurate. Additional subjective and objective data should be obtained to come up with an accurate diagnosis. Differential diagnoses such as syphilis, herpes simplex, and contact dermatitis should however be considered. In addition, further diagnostic investigations should be performed to come up with an accurate diagnosis.

References

Cox, C. L. (2019). Physical Assessment for Nurses and Healthcare Professionals. John Wiley & Sons. Forbes, H., & Watt, E. (2020). Jarvis’s Health Assessment and Physical Examination – E-Book: Australian and New Zealand. Elsevier Health Sciences. Perry, A. G., Potter, P. A., Ostendorf, W., & Laplante, N. (2021). Clinical Nursing Skills and Techniques—E-Book. Elsevier Health Sciences. Stephen, T. C., & Skillen, D. L. (2020). Canadian Nursing Health Assessment. Lippincott Williams & Wilkins.

Photo Credit: Getty Images

Patients are frequently uncomfortable discussing with healthcare professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital. Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to accurately assess patients with problems in these areas. In this Lab 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.

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.

By Day 7 of Week 10

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Patient Information:

D.S. Age 42 Caucasian Male S. CC: “Lower Back Pain” HPI: The patient is a 42-year-old white male who developed lower back pain one month ago. The pain is a sharp, stabbing pain that radiates to his left leg. His lower back pain increases with sitting for long periods, and he states the pain gets better when he stands. He states is has also been taking Motrin, which relieves the pain for about an hour or so. Motrin provides some relief from pain, but only for about an hour. He rates his pain currently at a 6/10. At worst, his pain is an 8/10.

Current Medications:

Lisinopril 10mg BID Atorvastatin 40 mg daily, Motrin 600 mg two every 4 to 6 hours as needed for pain. Allergies: No known drug, food, or environmental allergies. PMHx: HTN Hypercholesterolemia Hospitalized at age 19 for a staph infection PSHx: Left knee ACL repair 2002 Cholecystectomy 1998

Immunizations &Health Maintenance:

Last Tetanus 5 years Flu Shot in Nov 2017 Chicken Pox as a child, age 8 yrs. Soc Hx: M.S. is a construction worker who spends a lot of time lifting and standing. Personal/Social History: denies tobacco product use. Denies illicit drug use. Married for 18 years and has two children. Prohibits daily exercise but states he gets to exercise at his job frequently by walking frequently and lifting heavy

Fam Hx:

Son: Age 10. No concerns Daughter: Age 7, no concerns Mother- alive, 76 years old, breast cancer at 52 in remission. Father- deceased at age 68 from MI – history of CAD, MI. Sister-Alive- 38- HTN Maternal Grandmother- deceased at 88, dementia complications. HTN type 2 diabetes Maternal Grandfather – deceased at 76, stroke complications -HTN Hypercholesteremia Paternal grandfather- deceased 89 stroke – A fib, prostate cancer Maternal grandmother -deceased at 62 from a car accident. hypothyroidism HTN O

ROS:

General: No complaint of fever, chills, weakness, or fatigue. Denies recent weight loss or gain. He reports he is still ADL independent A&OX4. Heent: Eyes denies vision changes, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: Denies changes in hearing, sneezing, congestion, runny nose, or sore throat. Skin: denies rash or itching. Cardiovascular: denies chest pain, chest pressure, or chest discomfort. No palpitations or edema. Respiratory: No Complaint of no cough. Gastrointestinal: patient reports occasional heartburn. No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or bowel incontinent, no rectal pain or bleeding Genitourinary: Denies difficulty with urination, leakage, or incontinence. Denies odor or blood in the urine. Neurological: Denies headache, dizziness, and syncope. Denies paralysis, no ataxia, no numbness or tingling in the extremities. No issues with bowel or bladder control. No problems with memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history Musculoskeletal: Complaints of lower back pain radiating down the back of the left leg; sometimes, the pain increases when turning in bed. Reports walking with a limp when having pain. Denies leg numbness. Pain is relieved somewhat with his OTC Motrin. Declines any swelling, redness, or heat at joint sites. Bending at the waist, leg lifts, and difficulty squatting at work to lift small pallets of bricks. Reports frequent leg cramps, mostly left thigh, occasionally left calf. Denies heel or foot injury, recent known trauma, joint swelling, pain, or tenderness; denies obvious muscle weaknesses. Psychiatric-Reports irritability, difficulty concentrating, increased stress level due to pain over the last month, and concerns about his job related to missing work days related to back. Denies hx of anxiety attacks, past or current desire to harm himself or others. Endocrine: Denies temperature intolerance or changes in hair or skin, polyuria, polydipsia, excessive bruising, bleeding gums, or noted petechiae.

Physical exam:

VS: BP 139/72; P 7; R 18; T 97.6F; O2 SAT 99%; Wt. 225 lbs.; Ht 6’3”, pain 8/10 on a scale of 0-10 at rest General: presents as a well-developed, young adult Caucasian who appears his stated age. He is alert, oriented x4, and cooperative. The patient walks with a slight limp, HEENT: normocephalic head with equal distribution of hair. Conjunctivae are pink; sclera is white and without jaundice. PERRLA present, with pupils 3mm in size bilaterally. No exudate present. Nasopharynx and pharynx without erythema, lesions, or exudates. Mucous membranes are moist. Upper and lower teeth are in good condition and intact. The trachea is midline. No facial tenderness to light palpation Neck: Supple with no JVD or bruits, no adenopathy. No swelling was noted. normal ROM Chest/Lungs: equal symmetry of chest rise and fall. Lungs are clear to auscultation anteriorly and posteriorly—no wheezes, rhonchi, or stridor. Resonance noted to percussion bilaterally. Cardiovascular: RRR without a murmur. Good S1, S2. Radial posterior tibial, dorsalis pedis, and pedal pulse +2 bilaterally., Carotid or femoral bruits not prsent. . Normal color. Capillary refill less than 3 seconds. No cyanosis or clubbing is present. Abdomen: Flat, soft NABS x4. Non-tender, no inguinal nodes noted. Genital/Rectal: Deferred. Musculoskeletal: Gait posture upright and smooth with even strides. Strong muscular build. Normal spinal curvature with symmetrical alignment with the scapula, iliac crests, and gluteal crease. Legs equal length. No swelling, deformities, redness, warmth, or pain was noted in joints. Symmetrical development of upper and lower extremities. No erythema or deformities of joints. Feet without deformities. Note high arches Spine without point tenderness except at sciatic notch. Pain to the lower back when the leg is extended while the thigh is flexed when lying flat. Limited ROM of the right leg with pain at 40 degrees when lifting. ROM is limited to forward bending 10 inches from the floor. Pain to left buttock area and left posterior thigh with palpation—minimal flexion of the left knee due to pain. Ankle jerk diminished in the left ankle. Walking on toes causes increased pain.No; crepitus or stiffness to palpitation of joints. Positive Lasegues at 45 degrees -Positive Bragard’s test also increased with internal rotation more pronounced with left leg lift. Pelvic tilt and other forward flexion increased pain and radiculopathy. Questionable Neg hip pain with AFBER assessment, although limited due to eliciting back pain. Negative hip click. The pain was exacerbated with toe and heel walking and squats. No muscle atrophy- calves and thighs equal size bilaterally. Positive Left hamstring lightness more than right (Danis, 2019) Neurological: CN II-XII intact. Sensory neurology is intact to light touch, and the patient can toe and heel walk. Gait is stead with ambulation and limping noted. No observed muscle twitching or tremors. Proprioception intact L great toe. Spinothalamic using sharp/dull with decreased sensation distinction from left lateral mid-calf across ant lateral L foot to the toe. DTRs intact and. Negative Babinski. Leg muscle strength plus 4 left plus five right. Decreased dorsiflexion and plantar flexion strength in the left foot. Decreased knee flexion and weaker left gluteus maximus in the prone position. While sitting, hip abduction is softer on the left side. Skin: Warm and dry to the touch. Hair is evenly distributed over the scalp and body. No ecchymosis or edema. No noted rashes, open wounds, or lesions.

Diagnostic tests/labs:

CBC: used to confirm the diagnosis of infection or malignancy.
ERS-inflammatory response
Dipstick/UA- bladder involvement, possible kidney infection
MRI Magnetic resonance imaging (MRI) to evaluate soft tissue injury, such as disk herniations (Danis, 2019)

A Differential Diagnoses:

Lumbosacral Herniated Disc: The Jelly nucleus pulposus, the disc center, and the outermost layers are collectively called the annulus fibrosis. Facilitating the spine’s movement and providing support for the vertebrae disc degeneration or trauma can occur here. The nucleus herniates through the weakened layers of the outer disc and leaks out of the annulus fibrosis into the spinal canal (Traeger et al., 2021). While disc herniation is usually associated with ipsilateral symptoms, a few cases have been reported to present with contralateral symptoms n be a result of mechanical compression, ischemia, or inflammatory irritation of the nerve root.
In the case of a lumbar herniated disc, the weak spot and the annulus fibrosis are directly underneath the spinal nerve root, so a herniation in this area can put direct pressure on the nerve root that extends down the leg and any pinching or pressure on the nerve in the lower spine which can cause sciatica (Danis, 2019). Most sciatica symptoms result from lower back disorders L4 and S1 levels. Magnetic resonance imaging (MRI) scan is an appropriate tool to confirm the diagnosis and affected group of the spine. (Cunha et al., 2018)
Cauda Equina Syndrome. The cauda equina is a bundle of nerve fibers at the bottom of the spinal cord. When these become irritated by pressure or inflammation, it can cause cauda equina. Causes of cauda equina include spinal stenosis, inflammation or infection within the spinal canal, tumors, or injury to the spine. Symptoms will vary depending on which nerves are affected and the degree of nerve compression and subsequent irritation (Danis, 2019). Symptoms include severe low back pain and neurological problems in the central regions and lower limbs that may include urinary or bowel incontinence, loss of feeling, motor weakness, or loss of motor function in the legs, such as difficulty walking. Cauda equina syndrome is a severe medical emergency. Although nerve damage is rare in cauda equina syndrome, if left untreated, it can result in paralysis sensation below the lumbar spine and permanent loss of bladder and bowel control (Long et al., 2020)
Musculoskeletal Lumbar Strain.A lower back strain causing acute pain due to damage to the muscles and ligaments of the back is known as Musculoskeletal Lumbar Strain. These are often referred to as pulled muscles. The back is supported by a large complex group of muscles that hold up the spine, including the extensor flexor and oblique muscles. The soft tissues surrounding the spine enable bending forward, lifting, marching, and twisting movements. A lumbar muscle strain occurs when a back muscle is overstretched or torn, which damages the muscle fibers (Traeger et al., 2021). When one of the ligaments in the back tears, it is referred to as a sprain movement that puts stress on the back and results in pulled muscles; twisting while lifting, falling, or some sports could cause lumbar muscle strain (Danis, 2019). Symptoms include sudden localized pain that does not radiate into the leg. Muscle spasms can accompany tenderness in lower back muscle strain as the body tries to stabilize the injury. Acute pain from a lower back strain can resolve quickly, but levels of pain or flare-ups can continue for weeks or months after the initial injury, and after two weeks, back muscles can atrophy from lack of use and cause more pain. Many treatment options for lower back muscle strain include exercise, which will prevent atrophy (Hodges & Danneels, 2019).
Acute Pyelonephritisis an infection of the kidney. It may be acute or chronic. The cause may be retrograde or hematogenous. In adults, it is more frequent in women the men. Acute Pyelonephritis is defined as acute kidney inflammation that presents with fever, pain, and tenderness. Predisposing factors include urinary stasis, reflux calculi of the urinary tract, and damage to the spinal cord. Intercourse and pregnancy are also predisposing factors (Danis, 2019).

References:

Cunha, C., Silva, A. J., Pereira, P., Vaz, R., Gonçalves, R. M., & Barbosa, M. A. (2018). The inflammatory response in the regression of lumbar disc herniation. Arthritis Research & Therapy, 20(1). https://doi.org/10.1186/s13075-018-1743-4 Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby. Hodges, P. W., & Danneels, L. (2019). Changes in structure and function of the back muscles in low back pain: Different time points, observations, and Mechanisms. Journal of Orthopaedic & Sports Physical Therapy, 49(6), 464–476. https://doi.org/10.2519/jospt.2019.8827 Long, B., Koyfman, A., & Gottlieb, M. (2020). Evaluation and management of Cauda Equina Syndrome in the emergency department. The American Journal of Emergency Medicine, 38(1), 143–148. https://doi.org/10.1016/j.ajem.2019.158402 Traeger, A. C., Qaseem, A., & McAuley, J. H. (2021). Low back pain. JAMA, 326(3), 286. https://doi.org/10.1001/jama.2020.19715 Assessment is one of the skills that nurses should possess in their practice. Nurses use their assessment knowledge and skills in developing accurate diagnoses and plans of care for their patients. The assessment skills that nurses often use in their practice include history taking and physical examination such as observation, palpation, percussion, and auscultation. Assessment results also guide the evaluation of care given to the patients. Nurses use evaluation information to determine the accuracy of their diagnoses, plans, and interventions used to address the care needs of their patients. Therefore, this paper is an examination of a case study of client who presented to the clinic with genitourinary problem. The client came with a history of external pumps in her genital area, which are painless and rough. The history obtained from her shows that she had the last pap smear test three years ago, which was normal. The patient does not have any significant medical, family or surgical history. Therefore, the paper examines the subjective and objective data that should be obtained for the patient, diagnostic investigations and differential diagnoses for the client.

Additional Subjective Data

The nurse should focus on obtaining additional subjective data from the patient besides those in the case snapshot. The additional subjective data will guide the development of accurate diagnosis and treatment plan for the client. The nurse should obtain the information about additional symptoms that are associated with the external pumps on her genitalia (Stephen & Skillen, 2020). The nurse should obtain information such as size, shape, any discharge, or changes in the pumps that might have occurred over the past in terms of appearance. The nurse should also obtain additional information about any history of similar pumps in the past. A history of closely related pumps of the genital area could guide the development of diagnoses such as warts in the patient. There is also the need for the nurse to obtain information related to medication use by the patient. A history of medication uses such as those used in managing the pumps could aid in determining the cause of the problem (Stephen & Skillen, 2020). History on medication use could also guide the determination of whether the pumps are attributable to side effects or adverse reactions to a drug. Moreover, the nurse should obtain information about the use of any irritants in the past that might have caused the pump. For example, information about the types of soaps that the patient uses should be obtained. The client should also be asked about her sexual preferences. This will provide information about her sexual habits, which might have led to the development of the pumps. The effect of the pumps on the self-perception of the client should also be obtained. The nurse should try to rate the effect of the pumps on her self-image and self-esteem using an appropriate rating scale (Forbes & Watt, 2020). The additional subjective data that may be needed include history of skin problems such as eczema, menstrual history, and occupational history to determine any risk factors in her workplace place.

Additional Objective Data

Additional objective data should also be obtained from the client to increase the accuracy of the diagnosis. The nurse should have performed a rectal examination. The examination could have provided clues such as the presence of hemorrhoids or anal fissures. The nurse should have also provided information about the general appearance of the client. The general appearance could have provided clues on the social, emotional and physical impact of the pumps on the client (Cox, 2019). The nurse should have also performed head to toe examination of the client. The examination could have included the assessment of the skin to determine the existence of undetected skin lesions. The nurse should have also examined the oral cavity for any lesions, neck for inflamed lymph nodes and neck rigidity. The nurse should have also assessed the chest for any abnormal findings such as appearance, shape, or palpitations on auscultation (Champagne et al., 2017). The above information could have guided the accuracy of the diagnoses made by the nurse.

Whether Subjective and Objective Data Support the Assessment

Diagnostics

Current Diagnosis

Differential Diagnoses

Conclusion

References

Champagne, B. J., Steele, S. R., Hendren, S. K., Bakaki, P. M., Roberts, P. L., Delaney, C. P., … & MacRae, H. M. (2017). The American Society of Colon and Rectal Surgeons assessment tool for performance of laparoscopic colectomy. Diseases of the Colon & Rectum, 60(7), 738-744. Cox, C. L. (2019). Physical Assessment for Nurses and Healthcare Professionals. John Wiley & Sons. DOI: https://doi.org/10.1097/DCR.0000000000000817 Forbes, H., & Watt, E. (2020). Jarvis’s Health Assessment and Physical Examination – E-Book: Australian and New Zealand. Elsevier Health Sciences. Kohtz, C., Brown, S. C., Williams, R., & O’Connor, P. A. (2017). Physical assessment techniques in nursing education: a replicated study. Journal of Nursing Education, 56(5), 287-291. https://doi.org/10.3928/01484834-20170421-06 Perry, A. G., Potter, P. A., Ostendorf, W., & Laplante, N. (2021). Clinical Nursing Skills and Techniques—E-Book. Elsevier Health Sciences. Stephen, T. C., & Skillen, D. L. (2020). Canadian Nursing Health Assessment. Lippincott Williams & Wilkins.

Grading Criteria

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What’s Coming Up in Module 4?

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images Next week, you will consider how evidence-based practice guidelines and ethical considerations factor into health assessments. You specifically explore evidence-based practice guidelines and ethical considerations for specific scenarios.

Week 11 Final Exam

Photo Credit: [DirtyDog_Creative]/[Vetta]/Getty Images Next week, you take your Final Exam, which will cover the topics and resources from Weeks 7, 8, 9, and 10 for this course. Please take the time to review and plan your time accordingly so that you may be better prepared for your exam.

Next Module

To go to the next Module: Module 4

Week 10: Special Examinations—Breast, Genital, Prostate, and Rectal

One critical element of any physical exam is the ability of the examiner to put the patient at ease. By putting the patient at ease, nurses are more likely to glean quality, meaningful information that will help the patient get the best care possible. When someone feels safe, listened to, and cared about, exams often go more smoothly. This is especially true when dealing with issues concerning breasts, genitals, prostates, and rectums, which are subjects that many patients find difficult to talk about. As a result, it is important to gain a firm understanding of how to gain vital information and perform the necessary assessment techniques in as non-invasive a manner as possible. For this week, you explore how to assess problems with the breasts, genitalia, rectum, and prostate.

Learning Objectives

Students will:

Evaluate abnormal findings on the genitalia and rectum
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the breasts, genitalia, prostate, and rectum

Learning Resources

Required Readings (click to expand/reduce) Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Chapter 17, “Breasts and Axillae”This chapter focuses on examining the breasts and axillae. The authors describe the examination procedures and the anatomy and physiology of breasts.

Chapter 19, “Female Genitalia”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.

Chapter 20, “Male Genitalia”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 21, “Anus, Rectum, and Prostate”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.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center. Chapter 5, “Amenorrhea” Amenorrhea, or the absence of menstruation, is the focus of this chapter. The authors include key questions to ask patients when taking histories and explain what to look for in the physical exam. Chapter 6, “Breast Lumps and Nipple Discharge” This chapter focuses on the important topic of breast lumps and nipple discharge. Because breast cancer is the most common type of cancer in women, it is important to get an accurate diagnosis. Information in the chapter includes key questions to ask and what to look for in the physical exam. Chapter 7, “Breast Pain” Determining the cause of breast pain can be difficult. This chapter examines how to determine the likely cause of the pain through diagnostic tests, physical examination, and careful analysis of a patient’s health history. Chapter 27, “Penile Discharge” The focus of this chapter is on how to diagnose the causes of penile discharge. The authors include specific questions to ask when gathering a patient’s history to narrow down the likely diagnosis. They also give advice on performing a focused physical exam. Chapter 36, “Vaginal Bleeding” In this chapter, the causes of vaginal bleeding are explored. The authors focus on symptoms outside the regular menstrual cycle. The authors discuss key questions to ask the patient as well as specific physical examination procedures and laboratory studies that may be useful in reaching a diagnosis. Chapter 37, “Vaginal Discharge and Itching” This chapter examines the process of identifying causes of vaginal discharge and itching. The authors include questions on the characteristics of the discharge, the possibility of the issues being the result of a sexually transmitted infection, and how often the discharge occurs. A chart highlights potential diagnoses based on patient history, physical findings, and diagnostic studies. Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

Chapter 3, “SOAP Notes” (Previously read in Week 8)

Cucci, E., Santoro, A., DiGesu, C., DiCerce, R., & Sallustio, G. (2015). Sclerosing adenosis of the breast: Report of two cases and review of the literature. Polish Journal of Radiology, 80, 122–127. doi:10.12659/PJR.892706. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4356184/ Sabbagh , C., Mauvis, F., Vecten, A., Ainseba, N., Cosse, C., Diouf, M., & Regimbeau, J. M. (2014). What is the best position for analyzing the lower and middle rectum and sphincter function in a digital rectal examination? A randomized, controlled study in men. Digestive and Liver Disease, 46(12), 1082–1085. doi:10.1016/j.dld.2014.08.045 Westhoff , C. L., Jones, H. E., & Guiahi, M. (2011). Do new guidelines and technology make the routine pelvic examination obsolete? Journal of Women’s Health, 20(1), 5–10. This article describes the benefits of new technology and guidelines for pelvic exams. The authors also detail which guidelines and technology may become obsolete. Centers for Disease Control and Prevention. (2019). Sexually transmitted diseases (STDs). Retrieved from http://www.cdc.gov/std/# This section of the CDC website provides a range of information on sexually transmitted diseases (STDs). The website includes reports on STDs, related projects and initiatives, treatment information, and program tools.

Document: Final Exam Review (Word document)

Optional Resource

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

Chapter 8, “The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts” (Section 2, “The Breasts,” pp. 434–444)Section 2 of this chapter focuses on the anatomy and physiology of breasts. The section provides descriptions of breast examinations and common breast conditions.

Chapter 11, “The Female Genitalia and Reproductive System” (pp. 541–562)In this chapter, the authors provide an overview of the female reproductive system. The authors also describe symptoms of disorders in the reproductive system.

Chapter 12, “The Male Genitalia and Reproductive System” (pp. 563–584)The authors of this chapter detail the anatomy of the male reproductive system. Additionally, the authors describe how to conduct an exam of the male reproductive system.

Review of Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid” (pp. 445–527)

Required Media (click to expand/reduce)

Special Examinations – Breast, Genital, Prostate, and Rectal – Week 10 (14m)

Online media for Seidel’s Guide to Physical Examination It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 16 and 18–20 that relate to special examinations, including breast, genital, prostate, and rectal. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/ Assessment of the genitalia and rectum is vital in depicting genitourinary and gastrointestinal abnormalities respectively. A rectal examination is necessary to complete an abdominal exam. Meanwhile, assessment of the genitalia is usually sensitive and must be done in the presence of a chaperone. In the subsequent paragraphs, potential history, physical exam, and differential diagnosis shall be explored based on a case scenario of T.S. a 32-year-old woman who presents with dysuria, frequency, and urgency for two days. She is sexually active and has had a new partner for the past three months.

Subjective

A triad of urgency, frequency, and dysuria characterizes a pathology that is most likely in the urinary tract. Consequently, it is essential to inquire about associated symptoms such as hematuria, fever, and malaise. Association with malaise and fever is common in urinary tract infections. Similarly, it is important to inquire about the presence of any abnormal vaginal discharge, and burning sensation during urination since she is sexually active and a sexually transmitted infection might be the cause of her symptoms. Likewise, changes in the smell and color of the urine must be elicited as well as associated suprapubic pain. Related to sexually transmitted infections, it is crucial to inquire about the number of sexual partners if similar symptoms have manifested in her partner or the use of protection during intercourse (Garcia & Wray, 2022). Similarly, her last menstrual period must be known to determine if pregnant as this will impact the management (Bono et al., 2022). Additionally, a history of medication use, alcohol, smoking, and use of illicit drugs must be elicited. A history of contact with an individual with a chronic cough or TB prior to the occurrence of the previous symptoms must be elicited as urogenital TB may present similarly. Finally, it is crucial to inquire about any history of trauma or recent urethral catheterization as these are common risk factors for urinary tract infections.

Objective

The vital signs are mandatory in this patient as it is a pelvic exam. In the general exam, the mental and nutrition status of the patient must be noted. Additionally, a complete abdominal exam must be conducted as the patient has flank pain and suprapubic tenderness. Palpation of the abdomen for any masses and percussion of the flank for costovertebral angle tenderness must be done (Bono et al., 2022). Similarly, complete respiratory and cardiovascular exams must be conducted as a routine during the assessment of any patient. Finally, a digital rectal examination must be performed to exclude associated rectal abnormalities.

Assessment

In addition to urinalysis, STI, and pap smear testing, a complete blood count and urine culture must be conducted as the patient presents with signs of infection. Similarly, a pregnancy test must be conducted as this may complicate urinary tract infections. Additionally, she has no appetite and therefore a random blood sugar must be done to exclude hypoglycemia. Similarly, urea, creatinine, and electrolyte must be conducted to check the renal function as the patient has flank pain. Finally, Inflammatory markers such as ESR and CRP as well as blood cultures must be done as the patient has flank pain which may indicate pyelonephritis (Bono et al., 2022). Imaging tests are not necessary for the diagnosis of lower UTI. However, the patient has flank pain, and therefore, a CT scan of the abdomen and pelvis with or without IV contrast as well as an ultrasound of the kidneys and bladder must be done to identify any pathologies and outline the architecture of the kidney and bladder (Belyayeva & Jeong, 2022) The possible diagnoses include a urinary tract infection and a sexually-transmitted infection. Urinary tract infections refer to the infection of the bladder, urethra, ureters, or kidneys (Bono et al., 2022). UTIs are more common in women, a consequence of a short urethra and proximity of the anal and genital regions (Bono et al., 2022). A triad of frequency, dysuria, and urgency collectively defines the irritative lower urinary tract symptoms (Bono et al., 2022). Similarly, suprapubic tenderness is a key feature of lower urinary tract infections. However, the patient is also feverish and has flank pain which also denotes the potential for involvement of the upper urinary tract (Bono et al., 2022). T.S is also sexually active, a risk factor for urinary tract infection. A sexually transmitted infection is another possible diagnosis. T.S is sexually active and she has had her new partner for the last three months which is a key risk factor for this condition (Garcia & Wray, 2022). Most STIs present with suprapubic pain. Most STIs are asymptomatic and if symptomatic manifests with urethral discharge, vaginal discharge, pruritus, and pain (Garcia & Wray, 2022). T.S was negative for the aforementioned features. Other differential diagnoses include pyelonephritis, interstitial cystitis, and urethritis due to an STI. Pyelonephritis is of the renal pelvis and parenchyma (Belyayeva & Jeong, 2022). It is usually a complication of ascending bacterial infection of the bladder and manifests principally with frequency, dysuria, urgency, fever, malaise, flank pain, and suprapubic pain (Belyayeva & Jeong, 2022). Interstitial cystitis is a chronic noninfectious idiopathic cystitis associated with recurrent suprapubic pain (Daniels et al., 2018). It presents with urgency, frequency, suprapubic discomfort, and pain relieved by voiding. T.S has some of these features although the gradual onset of symptomatology and a duration of more than six weeks is required for the diagnosis of this condition (Daniels et al., 2018). Finally, urethritis secondary to an STI may present in females with only frequency, urgency, and dysuria with minimal or no vaginal discharge (Young et al., 2022).

Conclusion

Assessment of the genitalia and rectum is sensitive and may help identify abnormalities of the rectum and genitourinary tract. Most abnormalities of the genitourinary system particularly UTIs and STIs can be diagnosed clinically. Consequently, a comprehensive history and physical examination are mandatory. Most UTIs are common in females. Pregnancy must always be excluded in a patient presenting with features suggestive of a UTI.

References

Belyayeva, M., & Jeong, J. M. (2022). Acute Pyelonephritis. https://pubmed.ncbi.nlm.nih.gov/30137822/ Bono, M. J., Leslie, S. W., & Reygaert, W. C. (2022). Urinary Tract Infection. https://pubmed.ncbi.nlm.nih.gov/29261874/ Daniels, A. M., Schulte, A. R., & Herndon, C. M. (2018). Interstitial cystitis: An update on the disease process and treatment. Journal of Pain & Palliative Care Pharmacotherapy, 32(1), 49–58. https://doi.org/10.1080/15360288.2018.1476433 Garcia, M. R., & Wray, A. A. (2022). Sexually Transmitted Infections. https://pubmed.ncbi.nlm.nih.gov/32809643/ Young, A., Toncar, A., & Wray, A. A. (2022). Urethritis. https://pubmed.ncbi.nlm.nih.gov/30725967/ Genitourinary problems are a common occurrence in nursing practice. nurses utilize both subjective and objective data to develop accurate diagnoses and treatment plans for their patients. Therefore, the purpose of this paper is to examine a case study of a patient that presents with a genitourinary problem. The purpose of this paper is to examine the additional information needed in the subjective and objective portions, additional diagnostic studies, accepting or rejecting the diagnosis, and possible conditions that should be considered.

Subjective Portion

Additional subjective data should be obtained from the patient to guide the development of an accurate diagnosis. First, the nurse should ask the patient to describe the factors that precipitate or relieve the symptoms. The information will guide rule out potential causes of the client’s problem. The nurse should also obtain information about the treatments that were useda year ago when she experienced the same symptoms. Information about the patient’s sexual habits should also be obtained. This includes data about unprotected or protected sex. The nurse should also obtain data about douching, wearing tight undergarments, and scented underwear. The nurse should also ask if her partner has similar problem to rule out the potential of a sexually transmitted infection. Information about the color or smell of the urine should also be obtained. This will help rule out causes such as urinary tract infection(Ackley et al., 2021). Besides, information about any allergies to drugs should be obtained, as it will determine the client’ treatment options. Lastly, the information about the impact of the health problem should be obtained. This includes its effect on the ability of the patient too engage in her social and occupational roles.

Objective Portion

Additional information should also be obtained in the objective portion. One of them is the review of other systems that include respiratory and cardiovascular system. The review is important to rule out any other comorbidities the client may have. The nurse should also include information about the presence or absence of abdominal tenderness, organomegaly, or guarding. The data on the presence or absence of edema should also been included. This could help rule out renal problems such as kidney disease(Ackley et al., 2021). The information about any abnormal smell should have also been provided. Such information could have helped rule out causes such as sexually transmitted infections.

Assessment Supported

Subjective ad objective data support the assessment. Subjective data is the patient’s version of a health problem. It helps healthcare providers to understand the patient experiences with a disease and its impact on their health and wellbeing. The subjective data in the case study include the client’s presenting complains, past medical and surgical history, information about review of systems, and chief complain. Objective data refers to the information that healthcare providers obtain through methods such as inspection, palpation, auscultation, and percussion. The data validates subjective assessment information. The examples of objective data in the case study include vital signs and results of pelvic examination.

Diagnostic Tests

The healthcare provider should request for several diagnostic tests. One of them is urinalysis. Urinalysis should be done to determine the presence of white blood cells, blood, or glucose. Urine culture should also be done to determine if the cause of the problem is gram positive or negative organism. Complete blood count is also recommended to detect any abnormalities such as elevated white blood cell count, which will indicate an infection. Pelvic ultrasound may also be needed to rule out causes such as renal stones. VDRL should also be done to rule out sexually transmitted infections (Weese et al., 2021). A pap smear may also be required should the healthcare provider be interested in ruling out causes such ascervical cancer.

Rejection or Acceptance

I will accept the diagnosis of urinary tract infection and reject sexually transmitted infection. Patients diagnosed with urinary tract infections experience symptoms that align with those seen in the patient. They include dysuria, urgency, frequency, cloudy urine, strong-smelling urine, and pelvic pain(Neugent et al., 2020). Women are highly vulnerable to urinary tract infection than men due to the differences in the genitourinary structures.

Possible Conditions

As noted above, the client’s primary diagnosis is urinary tract infection. Urinary tract infection affects any part of the urinary tract such as the urethra, bladder, kidneys, and ureters. The symptoms associated with urinary tract infections include strong, persistent urge to urinate, burning sensation during urination, increased urinary frequency, cloudy urine, strong-smelling urine, and pelvic pain(Byron, 2019). The other differential that should be considered for the patient is pyelonephritis. Pyelonephritis is a complication of urinary tract infection. It develops from ascending causative organism for the urinary tract infection to the bladder and kidneys. The affected patients experience symptoms that include fever, abdominal and flank pain, dysuria, cloudy urine, blood or pus in urine, increased urinary frequency and urgency, and fish-smelling urine(Kolman, 2019). The additional symptoms that may be experienced include nausea, chills, vomiting, fatigue, mental confusion, and moist skin. The last differential to consider for the patient is renal stones. Renal stones or nephrolithiasis is a condition that develops from the deposition of salts and stones in the kidneys. Nephrolithiasis is associated with factors such as excess body weight, extreme dehydration, and diet. The affected patients experience symptoms that include sharp pain in the back and side below the ribs, pain radiating to the groin and lower abdomen, dysuria, and cloudy-smelling urine. There is also increased urgency, nausea and vomiting, and pink or read urine (Mayans, 2019).

Conclusion

Additional information is needed in the subjective and objective portions. I will accept the diagnosis of urinary tract infection. Additional diagnostic investigations are essential to develop an accurate diagnosis. The nurse should consider the differentials and narrow to a single cause in the treatment process. s

References

Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M. R., & Zanotti, M. (2021). Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates—E-Book. Elsevier Health Sciences. Byron, J. K. (2019). Urinary Tract Infection. Veterinary Clinics: Small Animal Practice, 49(2), 211–221. https://doi.org/10.1016/j.cvsm.2018.11.005 Kolman, K. B. (2019). Cystitis and Pyelonephritis: Diagnosis, Treatment, and Prevention. Primary Care: Clinics in Office Practice, 46(2), 191–202. https://doi.org/10.1016/j.pop.2019.01.001 Mayans, L. (2019). Nephrolithiasis. Primary Care: Clinics in Office Practice, 46(2), 203–212. https://doi.org/10.1016/j.pop.2019.02.001 Neugent, M. L., Hulyalkar, N. V., Nguyen, V. H., Zimmern, P. E., & De Nisco, N. J. (2020). Advances in Understanding the Human Urinary Microbiome and Its Potential Role in Urinary Tract Infection. MBio, 11(2), e00218-20. https://doi.org/10.1128/mBio.00218-20 Weese, J. S., Blondeau, J., Boothe, D., Guardabassi, L. G., Gumleyg, N., Papichh, M., Jesseni, L. R., Lappinj, M., Rankin, S., Westropp, J. L., & Sykes, J. (2021). International Society for Companion Animal Infectious Diseases (ISCAID) guidelines for the diagnosis and management of bacterial urinary tract infections in dogs and cats. 日本獣医腎泌尿器学会誌, 13(1), 46–63. https://doi.org/10.24678/javnu.13.1_46

Lab Assignment Assessing the Genitalia and Rectum

Subjective Portion

Objective Portion

The objective portion should include the patient’s anthropometric measurements of weight, height, and BMI, which help to assess the overall nutritional status. It lacks findings from the general survey (appearance, grooming, degree of distress, speech, attitude, posture, and gait), cardiovascular, and respiratory exam.

Assessment

The assessment findings in the SOAP note include UTI and STI. UTI is consistent with subjective findings of pain during urination, urinary frequency, urgency, elevated body temperature, and flank pain. Besides, physical findings of suprapubic tenderness support UTI (Holm et al., 2021). STI aligns with subjective findings of pain during urination, elevated body temperature, flank pain, and objective finding of suprapubic tenderness.

Diagnostic Tests

Diagnostic tests are appropriate for this case to help identify the cause of the urinary symptoms and confirm or rule out UTI and STI. Relevant diagnostic tests include urinalysis to assess for leukocytes and erythrocytes in urine. The results will be used to confirm or rule out UTI. If a UTI is confirmed, a Urine culture will be performed since it is the standard diagnostic test for UTI (Holm et al., 2021). The results will be used to identify the causative organism guiding treatment. In addition, a vaginal nucleic acid amplification test is appropriate, and the results will be used to confirm or rule out N. gonorrhoeae and Chlamydia trachomatis.

Current Diagnosis

I would accept UTI as a diagnosis since the patient has classic symptoms like dysuria, urinary frequency, urgency, flank pain, elevated body temperature, and suprapubic tenderness. On the other hand, I would reject STI as a diagnosis since the type of STI is not mentioned.

Three Possible Conditions That May Be Considered Differential Diagnosis

Urinary Tract Infection (UTI): The clinical manifestations of UTI include dysuria, urinary urgency and frequency, bloody urine, suprapubic tenderness, a sensation of a full bladder, flank pain, costovertebral angle tenderness, and systemic symptoms like fevers, chills, and malaise (AlShuhayb et al., 2022). UTI is a possible diagnosis since the patient presents with dysuria, urinary frequency, urgency, marked flank pain, elevated body temperature, and suprapubic tenderness. Acute Cystitis: Acute cystitis is an infection of the bladder. It typically presents with dysuria, hesitancy, incomplete voids, polyuria, suprapubic tenderness to palpation, gross hematuria, and low back pain (Frazier & Huppmann, 2020). The patient has dysuria and suprapubic tenderness, which are consistent with Acute cystitis. Nongonococcal urethritis (NGU): NGU is an inflammation of the urethra caused mainly by Mycoplasma genitalium, Chlamydia trachomatis, or Trichomonas vaginalis. Clinical manifestations include dysuria, urethral discomfort or pruritus, mucopurulent urethral discharge, erythema of the urethral meatus, and rectal pain or bleeding (Sell et al., 2021). NGU is a differential diagnosis based on the patient’s dysuria.

Conclusion

The subjective portion should have information on the characteristics of urine and contraceptive use in the HPI. It should also include current medication, immunization, family history, social history, and ROS of cardiovascular, respiratory, and genitourinary systems. The objective part should include anthropometric measurements and findings on cardiovascular and respiratory exams. The possible diagnoses are UTI, Cystitis, and Nongonococcal urethritis.

References

AlShuhayb, F. H., Alanazi, M. G., Alghizzi, A. A., Khinkar, H. J., Ali, F. N., Alnahari, E. H. H. O., … & Aleidi, H. A. (2022). An Overview on Urinary tract infection Diagnostic and Management Approach in Primary Health Care. Archives of Pharmacy Practice, 1, 15. https://doi.org/10.51847/3neIMfJIpm Frazier, R. L., & Huppmann, A. R. (2020). Educational Case: Acute Cystitis. Academic pathology, 7, 2374289520951923. https://doi.org/10.1177/2374289520951923 Holm, A., Siersma, V., & Cordoba, G. C. (2021). Diagnosis of urinary tract infection based on symptoms: how are likelihood ratios affected by age? a diagnostic accuracy study. BMJ open, 11(1), e039871. https://doi.org/10.1136/bmjopen-2020-039871 Sell, J., Nasir, M., & Courchesne, C. (2021). Urethritis: rapid evidence review. American family physician, 103(9), 553-558. Healthcare practitioners could analyze the rectum and genitalia by thoroughly analyzing the offered subjective and objective data. Analyzing the offered data is necessary in order to get correct findings. In light of this, the purpose of this essay is to investigate the case of T.S., a 32-year-old woman who has been experiencing urgency, frequency, and dysuria for the past two days without treating presenting clinical manifestations. The submitted objective and subjective data will be examined, examined, and new information will be added in order to make it more detailed. Additionally, pertinent diagnostic tests will be suggested following which it would be possible to state the differential diagnosis (Dains & Scheibel, 2019).

Analysis of Subjective Data

When obtaining subjective data on a patient with genitalia health conditions, an array of information is needed to ensure that one has captured all the relevant details that will help narrow down the possible differential diagnosis to just one. The initial complaint, “Increased frequency and pain with urination,” was a correct presentation of a portion of the history of presenting illness (HPI). The timing ought to be mentioned in the HPI as well; it was reported to have happened two days ago (Dains & Scheibel, 2019). It is also important to specify the location of the pain, which was identified as being around the genitalia according to the information given. To determine the location, system reviews that focus on the genitourinary system ought to be analyzed. To indicate whether the discomfort is permanent or intermittent, the frequency of the pain should be mentioned in the specifics. In response, the patient said that the pain started when urinating (Dains & Scheibel, 2019). Information on if the patient sought treatment and the actions taken should be included; in this

Assignment Lab Assignment Assessing the Genitalia and Rectum NURS 6512N-32

instance, the patient declared they did not undergo any kind of medical treatment. Details on whether the patient has ever had symptoms associated with the urgency and frequency should be also be provided. The involvement of the genitalia raises questions regarding the patient’s sexual habits that need to be addressed. In response, the patient said that in the last three months, she had engaged in sexual activity and dated someone new (Dains & Scheibel, 2019). 1. How the patient rates their pain on a scale of 1-10 and also information on how the presenting clinical manifestations have affected her usual daily activities should be provided (Dains & Scheibel, 2019). 2. Information on whether the patient attempted to treat her clinical manifestations at home together with the specific forms of treatment she might have used should be provided (Dains & Scheibel, 2019). 3. Due to the presenting clinical manifestations a system that should be assessed examined is the genital-urinary system and it should be checked whether the patient is experiencing hematuria, nocturia, any swelling and also any changes to the color of urine (Dains & Scheibel, 2019). 4. The gastrointestinal system should also be examined on presence of dullness or masses (Dains & Scheibel, 2019). 5. The patient’s social history should be assessed to find out whether the patient uses illicit drugs, their caffeine intake, whether they are stressed and if they can easily access healthcare. Additionally, information on whether the patient is using any over the counter drugs or has prescription drugs should be obtained together with the frequency and dose (Dains & Scheibel, 2019). 6. Also information on whether the patient had been hospitalized previously should be obtained as it will help in finding out whether thy had any procedures done such as urinary catheterization that could have led to the resenting signs and symptoms (Dains & Scheibel, 2019). 7. The characteristics of the pain the patient experiences should be identified such as whether it is stabbing, burning or itching (Dains & Scheibel, 2019). It’s crucial to consider past medical history, and in this instance, the patient revealed that he had had tonsillectomy and appendectomy as part of his surgical history. Providing details on a history of STIs (sexually transmitted illnesses) is also crucial. It could be useful to know whether there are any allergies, particularly while giving medication. It is imperative to ascertain whether the patient has had any recent vaccinations. To ascertain whether the patient’s illness is caused by a genetic disorder and if relatives have had a condition similar to their own, family history information should be available (Dains & Scheibel, 2019). It is also necessary to perform a study of the systems whereby the patient reported to experiencing difficulty sleeping due to flank pain. The patient should state any breathing problems in the respiratory system and any chest pain or edema in the cardiovascular system. The patient did not appear to be vomiting from the abdomen, despite having minimal appetite. The patient’s breasts should be checked at that time, and they should also report if they have ever had a previous breast exam (Dains & Scheibel, 2019). The examination of the genitourinary system was necessary because it was the source of the signs and symptoms that were described; additionally, one may inquire as to whether the urine smells or whether there is a vaginal discharge. Since the individual in question is female and may require further examination of her reproductive system, asking about the timing of her most recent menstrual period will help exclude out pregnancy as a potential explanation of the symptoms. Given that the patient acknowledged having sex, you can ask about their condom, contraceptive, and STI testing habits. Furthermore, it’s critical to find out whether the patient has undergone a pap smear (Dains & Scheibel, 2019).

Analysis of the Objective Data

The objective data should provide further details on the patient. This covers their overall manner, whether or not their answers to questions were appropriate, their cleanliness, posture, and mood, among other things. Additionally, as the pelvis is linked to the genesis of the exhibiting clinical symptoms, a pelvic examination ought to be carried out (Cheshire & Goldstein, 2018). Upon exploring the suprapubic area at the time of the pelvic exam, it was discovered that the uterus and adnexa were pain-free and in good condition. The cervix is normal, and there is no vaginal discharge. The vital signs were within normal range, with one notable exception of the temperature, that read 37.3 degrees Celsius and would suggest a minor illness (Ball, et al., 2015). 1. The patient’s general appearance should be examined (Ball, et al., 2015). 2. Examination of the various systems such as abdominal region, cardiovascular, skin, respiratory and genital urinary would be necessary as these systems would provide relevant information to related to the presenting clinical manifestations (Cheshire & Goldstein, 2018).

Analysis of the Assessment

The assessment is supported by both subjective and quantitative evidence. The patient had mentioned before to having the same clinical symptoms. The patient took no action that would have relieved the symptoms when they returned. Moreover, there was a correlation between the pain and both urgency and frequency. All of this confirms the principal complaint of the patient, which indicated a condition of the genitourinary system. The mentioned differentials are also relevant since the patient’s symptoms are consistent with these conditions since they affect the genitourinary system (Dains & Scheibel, 2019).

Recommended Diagnostic Tests

In order to determine the condition, the patient is suffering from there are diagnostics test to be carried out that include: 1. Complete blood count (CBC) – this is done find out the number of white blood cells and if elevated determine if there is an infection causing the resulting clinical manifestations (Ball, et al., 2015). 2. Pregnancy test – this is because if one is pregnant symptoms of a UTI could worsen hence explaining the resulting clinical manifestations (Ball, et al., 2015). 3. Urinalysis- this is done to examine renal function and aid rule out conditions such as pyelonephritis that could be causing the presenting clinical manifestations (Ball, et al., 2015). 4. Abdominal CT scan- this is due to the presenting clinical manifestation of flank pain hence the scan is done to find out whether there are any abnormalities in the abdominal region (Ball, et al., 2015) 5. Pap smear-conducting this test can help rule out a condition such as herpes simplex virus (HSV) that could be causing the presenting clinical manifestations (Ball, et al., 2015).

Possible Differential Diagnosis

The two possible diagnoses for this patient are could be either an STI or an UTI. Women are more prone to UTIs than men are because of their shorter urethra and the close proximity of the vaginal and anal regions. Three symptoms, urgency, frequency, and dysuria, characterize a disorder in the lower urinary tract. Suprapubic discomfort is a common symptom of upper urinary tract infections. On the other hand, the patient’s flank pain and fever point to an upper urinary tract issue (Bono, et al., 2022). An illness acquired through sexual contact is an additional possibility. The patient is sexually active, which is an additional risk factor for this disorder. She has been dating her new boyfriend for three months. Suprapubic discomfort is caused by most STIs. Sexually transmitted infections (STDs) can cause discomfort, vaginal discharge, and urethral discharge, even though the majority of them are asymptomatic (Garcia & Wray, 2022). 1. Cystitis- this illness causes inflammation of the bladder, mainly in women. Because the patient had previously reported experiencing similar symptoms, it is possible that mild cases resolved on their own. It appears with dysuria, frequency and urgency in the same way that the patient experienced them. These parallels make it feasible to conclude that the virus has resurfaced (McCance & Huether, 2019). 2. Pyelonephritis- in this condition there is damage to the parenchyma and renal pelvis, when damage occurs in these areas it results in the clinical manifestations the patient is presenting with thus it being a possible diagnosis (McCance & Huether, 2019). 3. Bacterial vaginosis- this is a condition whereby bacteria invades the human body causing clinical manifestations of itching and burning similar to what the patient is presenting with thus it being a likely diagnosis (Garcia & Wray, 2022). 4. Urethritis- this is an inflammation in the urethra whereby women present with frequency, urgency and dysuria similar to what the patient is presenting with thus it being a likely diagnosis (Bono, et al., 2022). 5. Yeast infection – this condition presents with clinical manifestations of burning, a discharge and itching due to a fungal infection similar to what the patient is presenting with thus it being a likely diagnosis (Garcia & Wray, 2022).

Conclusion

To identify anomalies of the genitourinary tract and rectum, a comprehensive examination of the genitalia and rectum might be utilized. The majority of genitourinary illnesses, including STIs and UTIs, can be identified clinically. Consequently, a complete physical examination and medical history are required. Most incidences of UTIs occur in women. From the moment a patient presents with UTI symptoms, pregnancy needs to be ruled out (Dains & Scheibel, 2019).

References

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. Case Study Assignment: Assessment Tools and Diagnostic Tests in Adults and Children Bono, M. J., Leslie, S. W., & Reygaert, W. C. (2022). Urinary Tract Infection. https://pubmed.ncbi.nlm.nih.gov/29261874/ Cheshire, W. P., & Goldstein, D. S. (2018). The physical examination as a window into autonomic disorders. Clinical Autonomic Research, 28(1), 23-33. Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby. Garcia, M. R., & Wray, A. A. (2022). Sexually Transmitted Infections. https://pubmed.ncbi.nlm.nih.gov/32809643/ McCance, K. L., Huether, S. E., BRASHERS, V. L., & ROTE, N. S. (2019). Pathophysiology: The biologic basic for diseases in adults and children (No. ed. 8). Elsevier.

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Content

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.	Points Range: 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.	Points Range: 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.	Points Range: 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.	Points Range: 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.	Points Range: 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.	Points Range: 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.	Points Range: 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.	Points Range: 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?	Points Range: 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.	Points Range: 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.	Points Range: 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.	Points Range: 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?	Points Range: 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.	Points Range: 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.	Points Range: 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.	Points Range: 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 differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.	Points Range: 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.	Points Range: 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.	Points Range: 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.	Points Range: 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.	Points Range: 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.	Points Range: 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.	Points Range: 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.	Points Range: 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	Points Range: 5 (5%) – 5 (5%)Uses correct grammar, spelling, and punctuation with no errors.	Points Range: 4 (4%) – 4 (4%)Contains a few (1 or 2) grammar, spelling, and punctuation errors.	Points Range: 3 (3%) – 3 (3%)Contains several (3 or 4) grammar, spelling, and punctuation errors.	Points Range: 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.	Points Range: 5 (5%) – 5 (5%)Uses correct APA format with no errors.	Points Range: 4 (4%) – 4 (4%)Contains a few (1 or 2) APA format errors.	Points Range: 3 (3%) – 3 (3%)Contains several (3 or 4) APA format errors.	Points Range: 0 (0%) – 2 (2%)Contains many (≥ 5) APA format errors.
Total Points: 100

Name: NURS_6512_Week_10_Assignment_Rubric