Lab Assignment: Assessing the Genitalia and Rectum

Lab Assignment: Assessing the Genitalia and Rectum

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.

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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.
***The assignment for this week is an analysis of a SOAP note for the genitalia/rectum. As in the previous SOAP note analysis, this should be completed in a narrative format and answer all the questions listed in the assignment within the module.
Genitourinary Assessment
CC: Increased frequency and pain with urination
HPI:
T.S. is a 32-year-old woman who reports that for the past two days, she has dysuria, frequency, and urgency. Has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months.
Medical History:
None
Surgical History:
Tonsillectomy in 2001
Appendectomy in 2020
Review of Systems:
General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
Abdominal: Denies nausea and vomiting. No appetite
Objective
VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.
Pelvic Exam:
mild tenderness to palpation in the suprapubic area
bimanual pelvic examination reveals a normal-sized uterus and adnexae
no adnexal tenderness.
No vaginal discharge is noted.
The cervix appears normal.
Diagnostics: Urinalysis, STI testing, Papsmear
Assessment:
UTI
STI

Assessing the Genitalia and Rectum

Subjective Portion Analysis

Within the context of the case, the client mentioned that she engages in sexual activity and has been seeing a new lover for the last three months. Because of this, her healthcare professional should inquire further about her sexual behaviors, including her history and current use of contraception and her use of protection. This will also investigate the possibilities of diseases that are sexually transmitted. The objective is to ensure one raises the relevant questions so they can gather the details they require to establish an accurate diagnosis and put up a therapeutic approach that will address the patient’s specific needs. It is imperative that medical professionals constantly inquire about any known allergies or other sensitivities that their patients may have. The following are examples of more details that must be incorporated into the subjective information:

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• Factors that may be aggravating or alleviating the pain as well as when it started, where it was, its nature, how it progressed over time, and if it was radiating
• Urinary symptoms include pain, blood in the urine, or incontinence.
• Color and smell of urine
• Whether symptoms are recurrent, intermittent, or constant
• Vaginal discharge or bleeding
• Menstrual and obstetric history
• Sexual practices
• Potential contact with potentially harmful substances
• Medication history
• The medical history of the family

Objective Portion Analysis

In order to correctly evaluate the client and exclude any possibilities of a diagnosis, the objective information should include specifics on the assessment of all of the client’s bodily systems. It is essential to have a broad understanding of the client’s state of health in order to examine the throat and mouth for any additional lesions or ulcers and determine whether or not the lymph nodes are swollen. The healthcare professional has to do a thorough examination of the client from head to toe and find out additional information about the client’s sexual history and current behaviors in order to exclude any other possible diagnosis. The patient’s vitals are essentially normal, with the exception of the pulse reading of 102, which suggests that the patient may be dehydrated. Infection, inflammation, or other disorders like hernias or kidney stones might be the cause of mild soreness in the suprapubic region when palpation is performed. The following are examples of more items that should be included in the objective information:

• Assessment of the patient’s general physical condition, from head to toe
• Skin test to check for swelling and dehydration
• Inspection of the breasts
• An examination of the abdomen to check for abdominal masses, pregnancy, a palpable bladder, and tenderness
• A thorough examination of the patient’s external genitalia
• A thorough inspection of the cervix as well as the vaginal wall

Diagnostic Tests

The following categories of diagnostic procedures might be relevant for this specific case:

• HPV testing using a swab and blood samples. It is only possible to identify someone with HPV if they have tumors that are evident in their genital area or if the results of their cervical screening are abnormal (Thomsen et al., 2020)
• Urinalysis in order to check for pathogens as well as blood cells
• Urine culture to identify the types of bacteria that are present in the urine
• Kidney function tests to assess kidney function and check for acute renal failure.
• A swab of the vaginal canal as part of a test for sexually transmitted infections
• Pregnancy test to determine whether or not a pregnancy is present
• An ultrasound of the pelvis to examine the genitourinary system and look for any abnormalities
• An x-ray of the kidney, ureter, and bladder to look for any illness, abnormalities, or dysfunction in either the bladder or kidney.

Differential diagnosis

Since the evaluation is substantiated by both subjective and objective evidence, the current diagnosis of STIs and UTIs may be considered reliable. In addition, the assessment is supported by a urinalysis and testing for STIs. The following are some other medical issues that should also be taken into consideration while attempting to establish a differential diagnosis for this client:

• Acute Pyelonephritis: This is one of the most frequent illnesses that affect the kidneys, and it is caused by a pathogenic bacteria that leads to irritation in the kidneys. It develops as an effect of an ascending UTI that invades the kidneys after starting in the bladder (Belyayeva & Jeong, 2019).
• Pelvic inflammatory disease (PID): This illness is typically brought on by the transmission of germs brought on by sexually transmitted diseases from the vagina to the uterus, ovaries, or fallopian tubes (Mayo Clinic, 2018). Fever and pelvic discomfort are two of the most prevalent symptoms. Vaginal discharge might occur.
• Kidney stones: These are solid formations of minerals and acid salts that have attached to one another in urine with a high concentration (National Kidney Foundation, 2017). The most typical indication is acute pain, which manifests itself more often on one side of the abdomen and is frequently accompanied by feelings of nausea.

References

Belyayeva, M., & Jeong, J. M. (2019). Acute pyelonephritis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519537/

Mayo Clinic. (2018). Pelvic inflammatory disease (PID) – Symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/pelvicinflammatory-disease/symptoms-causes/syc-20352594

National Kidney Foundation. (2017, February 13). Kidney Stones. National Kidney Foundation. https://www.kidney.org/atoz/content/kidneystones

Thomsen, L. T., Kjær, S. K., Munk, C., Frederiksen, K., Ørnskov, D., & Waldstrøm, M. (2020). <p>Clinical performance of human papillomavirus (HPV) testing versus cytology for cervical cancer screening: Results of a large Danish implementation Study</p>. Clinical Epidemiology, 12, 203-213. https://doi.org/10.2147/clep.s243546