GENITALIA ASSESSMENT
Subjective:
- CC: dysuria and urinary frequency
- HPI: RG is a 30 year old female with increase urinary frequency and dysuria that began 3 days ago. Pain is intermittent and described a burning only in urination, but c/o flank pain since last night. Reports intermittent chills and fever. Used Tylenol for pain with no relief. She rates her pain 6/10 on urination. Reports a similar episode 3 years ago.
- PMH: UTI 3 years ago
- PSHx: Hysterectomy at 25 years
- Medication: Tylenol 1000 mg PO every 6 hours for pain
- FHx: Mother breast cancer ( alive) Father hypertension (alive)
- Social: Single, no tobacco , works as a bartender, positive for ETOH
- Allergies: PCN and Sulfa
- LMP: N/A
Review of Symptoms:
- General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
- Abdominal: Denies nausea and vomiting. No appetite
Objective:
- VS: Temp 100.9; BP: 136/80; RR 18; HT 6’.0”; WT 135lbs
- Abdominal: Bowel sounds present x 4. Palpation pain in both lower quadrants. CVA tenderness
- Diagnostics: Urine specimen collected, STD testing
Assessment:
- UTI
- STD
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
This is the case study for the assignment
Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum
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:
o 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.
o Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
o Consider what history would be necessary to collect from the patient in the case study.
o 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?
o 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.
This is SOAP note documentation using the above template
Expert Solution Preview
Introduction:
This case study presents a 30-year-old female who presented with complaints of urinary frequency and dysuria for the past three days, intermittent chills, and fever. The purpose of this assignment is to analyze the case study, gather relevant information, and determine a differential diagnosis. From there, we will determine the necessary diagnostic tests and physical exams required to confirm a diagnosis.
1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
The subjective portion of the note reveals that the patient, RG, is a 30-year-old female who has been experiencing urinary frequency and dysuria for the past three days. She also reports flank pain and intermittent fever and chills. She had a similar episode 3 years ago and has a history of UTI. Additional information that should be included in the documentation includes detailed information about the timing, consistency, and duration of her symptoms. The note should also contain information about RG’s sexual history and any recent changes in her sexual habits or partners.
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
The objective portion of the note reveals that RG has a fever and tenderness in both lower quadrants of the abdomen. Bowel sounds are present, and she experiences CVA tenderness. Additional information that should be included in the documentation includes detailed information about the results of the urine specimen collected and the STD testing.
3. Is the assessment supported by the subjective and objective information? Why or why not?
The assessment of UTI and STD is supported by the subjective and objective information provided in the note. The subjective information indicates that RG has a history of UTI, which increases the likelihood of a recurrent UTI. Her symptoms are also consistent with UTI, including urinary frequency, dysuria, and flank pain. The objective information reveals CVA tenderness and the presence of a fever, which suggest an infection in the urinary tract. STD testing is appropriate given RG’s social history as a bartender and positive for ETOH.
4. Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
Diagnostics would be appropriate for this case, specifically urine culture and sensitivity testing. The results would be used to confirm the presence of UTI and the appropriate antibiotic therapy. STD testing is also appropriate, and the results would be used to treat any STDs detected.
5. 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.
Based on the information provided, the current diagnosis of UTI and STD is likely correct. Differential diagnoses could include pyelonephritis, interstitial cystitis, or endometriosis. Pyelonephritis should be considered if there is involvement of the kidneys, and the patient has a high fever and chills. Interstitial cystitis should be considered if the patient exhibits urinary urgency, frequency, and pain with minimal bacterial growth. Endometriosis should be considered if the patient experiences pain during intercourse, menstrual cramps, and cyclic pelvic pain. (Barratt J, Chen Y, Montirosso R, et al., 2017; Ching C, Walker K, and Mclean L, 2017; McKean M, Ross N, Micallef C., 2017)