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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:
As a medical professor, it is important to design assignments and assessments that challenge and test the knowledge and skills of medical college students. In this case, the assignment involves assessing the genitalia and rectum of a patient with abnormal findings. The objective is to prepare advanced practice nurses to accurately assess patients with problems in these areas.
Question 1: Analyze the subjective portion of the note. List additional information that should be included in the documentation.
The subjective portion of the note provides important information regarding the patient’s chief complaint, history of present illness, past medical history, family history, social history, and allergies. Additional information that should be included in the documentation includes the patient’s sexual history, use of contraceptives, history of sexually transmitted infections, and any recent changes in sexual partners. It is also important to document the patient’s level of education and understanding of their condition, as well as any psychosocial factors that may influence their health status.
Question 2: Analyze the objective portion of the note. List additional information that should be included in the documentation.
The objective portion of the note provides information regarding the patient’s vital signs, physical examination, and diagnostic tests. Additional information that should be included in the documentation includes the patient’s skin, hair, and nail condition, as well as the appearance and characteristics of any genital and rectal abnormalities. It is important to include the size, location, color, and texture of any lesions or masses, as well as any associated symptoms. Any neurological or musculoskeletal abnormalities should also be documented.
Question 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. The patient reports symptoms consistent with a UTI, including dysuria, urinary frequency, and intermittent chills and fever. The physical examination reveals tenderness in both lower quadrants of the abdomen and CVA tenderness. The urine specimen collected and STD testing are also consistent with the assessment of a UTI and STD.
Question 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 to confirm the diagnosis of UTI and STD. The urine specimen collected can confirm the presence of a UTI, while STD testing can confirm the presence of an STD. The results of the tests would be used to make a diagnosis and to determine the appropriate treatment for the patient.
Question 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 subjective and objective information, the current diagnosis of UTI and STD appears to be accurate. Three possible conditions that may be considered as a differential diagnosis for this patient include pyelonephritis, interstitial cystitis, and bladder cancer. Pyelonephritis can present with similar symptoms as a UTI, but with more severe flank pain and fever (Gupta & Hooton, 2013). Interstitial cystitis can cause symptoms similar to those of a UTI, but without evidence of infection in the urine (Clemens et al., 2014). Bladder cancer can cause dysuria and hematuria, with or without urinary frequency (Steinberg et al., 2016). Further diagnostic testing may be necessary to confirm or rule out these conditions.
