Feb 23, 2024 NURS 6512 Lab Assignment Assessing the Genitalia and Rectum
NURS 6512 Lab Assignment Assessing the Genitalia and Rectum
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
Submit your Assignment.
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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 dete
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