Feb 23, 2024 Assignment 1: Assessing the Genitalia & Rectum
Assignment 1: Assessing the Genitalia & Rectum
Assignment 1: Assessing the Genitalia & Rectum
Patients are frequently uncomfortable discussing with health care 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 assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
In this assignment, you will analyze a SOAP 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.
GENITALIA ASSESSMENT
Subjective:
CC: “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 over 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.PMH: AsthmaMedications: Symbicort 160/4.5mcgAllergies: NKDAFH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERDSocial: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
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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 3 different references from current evidence based literature.
Assignment 1: Assessing the Genitalia and Rectum
Patients are frequently uncomfortable discussing with health care 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 assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
In this assignment, you will analyze a SOAP 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.
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GENITALIA ASSESSMENT
Subjective:
CC: “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 over 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.PMH: AsthmaMedications: Symbicort 160/4.5mcgAllergies: NKDAFH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERDSocial: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)Objective:
VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbsHeart: RRR, no murmursLungs: CTA, chest wall symmetricalGenital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact with a healed episiotomy scar present. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labiaAbd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, neg McBurneyDiagnostics: HSV specimen obtainedAssessment:
ChancrePLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.To prepare:
With regard to the SOAP note case study provided:
Review this week’s Learning Resources, and consider the insights they provide about the case study.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.
To complete:
Refer to Chapter 5 of the Sullivan text. Analyze the SOAP note case study. Using evidence based resources, 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 3 different references from current evidence based literature.
You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.
Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.
Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.
The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.
ADDITIONAL INSTRUCTIONS FOR THE CLASS
Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation
Your initial responses to the mandatory DQ do not count toward participation and are graded separately.In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.It is best to paraphrase content and cite your source.
LopesWrite Policy
For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.I do not accept assignments that are two or more weeks late unless we have worked out an extension.As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me:Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.
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 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.
The SOAP note concerns T.S, a 32-year-old female with symptoms of pain when voiding, urinary frequency, and urgency that has lasted two days. She mentions that she had similar symptoms years back. She also reports having flank pain that disrupts her sleep, and she feels warm. Physical exam findings include mild suprapubic tenderness. The purpose of this paper is to analyze the SOAP note, identify additional information needed, and describe likely diagnoses.
Subjective Portion
The HPI in the subjective portion should include information describing the timing of the dysuria. This includes whether the dysuria occurs at the start or end of voiding to establish the underlying pathology. Dysuria at the start suggests urethral pathology, while at the end of voiding suggests bladder pathology (AlShuhayb et al., 2022). The HPI should also include the persistence and severity of the dysuria. In addition, information on the characteristics of urine should be provided, for instance, the amount of urine and if the urine is malodorous, cloudy, or bloody.
Information on the patient’s contraceptive use should be included in the HPI. The subjective portion should also include the client’s immunization history, current medications, reproductive history, including menstrual history, family history, and social history. Furthermore, the review of systems should have included each body system and indicated pertinent positives and negatives.
Objective Portion
The objective portion only contains findings from vital signs and pelvic exam. It should include anthropometric measures, height, weight, and BMI, vital in determining the client’s general nutritional status. In addition, physical findings from general, cardiovascular, and respiratory exams should be included since they are vital body systems. Findings from the examination of the external genitalia should be included to identify if the patient has vulvar ulcers, vesicles, pustules, mucosal inflammation, or vaginal discharge (AlShuhayb et al., 2022).
Assessment Supported
The identified assessment findings are UTI and STI. The subjective findings of dysuria, urinary frequency, urgency, and flank pain support UTI. It is also supported by objective findings of suprapubic tenderness (Czajkowski et al., 2021). STI is supported by the findings of dysuria, flank pain, feeling warm, and suprapubic tenderness.
Diagnostic Tests
Appropriate diagnostic tests include dipstick urinalysis, urine culture, blood culture, and vaginal nucleic acid amplification test (NAAT). Urinalysis is the most helpful diagnostic test in a patient with dysuria. Urine culture is indicated for patients with risk factors for complicated UTI or those who do not respond to initial therapy (Tai et al., 2022). A blood culture will be indicated since the patient reports feeling warm to, rule out systemic infection. In addition, vaginal NAAT will identify the presence of Chlamydia trachomatis and Neisseria gonorrhoeae.
Rejection or Acceptance
UTI is consistent with the patient’s pain symptoms when voiding, increased frequency, urgency, flank pain, and suprapubic tenderness. Thus, I would accept UTI as a diagnosis. STI is a broad term for other STIs; the diagnosis should be specific. Besides, the patient does not have sufficient physical findings to support STI; thus, I would reject the diagnosis.
Possible Conditions
Urinary Tract Infection (UTI):UTI in females present with symptoms like dysuria, a sensation of a full bladder, urinary urgency, frequency, suprapubic tenderness, flank pain, and blood in the urine (Jelly et al., 2022). It is also characterized by systemic symptoms such as fevers, chills, and malaise. The patient’s dysuria, increased frequency, urgency, flank pain, feeling warm, and mild suprapubic tenderness makes UTI a possible diagnosis.
Cystitis: This is a bladder infection. The onset of symptoms is usually sudden. Typical manifestations include dysuria, urinary frequency, urgency, and passing small volumes of urine (Frazier & Huppmann, 2020). Other common symptoms are suprapubic pain, low back pain, and nocturia. The patient has dysuria, increased frequency, urgency, and suprapubic tenderness, making Cystitis a possible diagnosis.
Ureth
ritis: This is inflammation of the urethra. Clinical features include urethral discharge dysuria, urethral irritation, or itch (Sadoghi et al., 2022). This is a differential diagnosis owing to the patient’s history of dysuria.
Conclusion
The subjective portion should have additional information to describe the dysuria and characteristics of urine. The ROS should have included pertinent negatives and positives from other systems. The objective portion lacks the anthropometric measurements and findings from general, cardiovascular, respiratory, and external genitalia exams. UTI is an acceptable diagnosis, but STI should be
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