Feb 23, 2024 Assignment : Genitalia and Rectum
Assignment : Genitalia and Rectum
Assignment : Genitalia and Rectum
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).
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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 rejected due to a lack of adequate physical findings to support it. The possible diagnoses are UTI, cystitis, and urethritis.
References
AlShuhayb, F. H., Alanazi, M. G., Alghizzi, A. A., Khinkar, H. J., Ali, F. N., Alnahari, E. H. H. O., … & Aleidi, H. A. (2022). An Overview on Urinary tract infection Diagnostic and Management Approach in Primary Health Care. Archives of Pharmacy Practice, 1, 15. https://doi.org/10.51847/3neIMfJIpm
Czajkowski, K., Broś-Konopielko, M., & Teliga-Czajkowska, J. (2021). Urinary tract infection in women. Przeglad menopauzalny = Menopause review, 20(1), 40–47. https://doi.org/10.5114/pm.2021.105382
Frazier, R. L., & Huppmann, A. R. (2020). Educational Case: Acute Cystitis. Academic pathology, 7, 2374289520951923. https://doi.org/10.1177/2374289520951923
Jelly, P., Verma, R., Kumawat, R., Choudhary, S., Chadha, L., & Sharma, R. (2022). Occurrence of urinary tract infection and preventive strategies practiced by female students at a tertiary care teaching institution. Journal of Education and health promotion, pp. 11, 122. https://doi.org/10.4103/jehp.jehp_750_21
Sadoghi, B., Kränke, B., Komericki, P., & Hutterer, G. (2022). Sexually transmitted pathogens causing urethritis: A mini-review and proposal of a clinically based diagnostic and therapeutic algorithm. Frontiers in medicine, 9, 931765. https://doi.org/10.3389/fmed.2022.931765
Tai, L. H., Ho, S. W., Yeh, C. B., & Chen, C. C. (2022). Woman With Dysuria. Annals of Emergency Medicine, 79(5), e103-e104. https://doi.org/10.1016/j.annemergmed.2021.11.012
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Assessment of the genitalia and rectum is vital in depicting genitourinary and gastrointestinal abnormalities respectively. A rectal examination is necessary to complete an abdominal exam. Meanwhile, assessment of the genitalia is usually sensitive and must be done in the presence of a chaperone. The purpose of this paper is to explore the potential history, physical exam, and differential diagnosis based on a case scenario of T.S. a 32-year-old woman who presents with dysuria, frequency, and urgency for two days. She is sexually active and has had a new partner for the past three months.
Subjective
A triad of urgency, frequency, and dysuria characterizes a pathology that is most likely in the urinary tract. Consequently, it is essential to inquire about associated symptoms such as hematuria, fever, and malaise. Association with malaise and fever is common in urinary tract infections. Similarly, it is important to inquire about the presence of any abnormal vaginal discharge, and burning sensation during urination since she is sexually active and a sexually transmitted infection might be the cause of her symptoms. Likewise, changes in the smell and color of the urine must be elicited as well as associated suprapubic pain. Related to sexually transmitted infections, it is crucial to inquire about the number of sexual partners if similar symptoms have manifested in her partner or the use of protection during intercourse (Garcia & Wray, 2022).
Similarly, her last menstrual period must be known to determine if pregnant as this will impact the management (Bono et al., 2022). Additionally, a history of medication use, alcohol, smoking, and use of illicit drugs must be elicited. A history of contact with an individual with a chronic cough or TB prior to the occurrence of the previous symptoms must be elicited as urogenital TB may present similarly. Finally, it is crucial to inquire about any history of trauma or recent urethral catheterization as these are common risk factors for urinary tract infections.
Objective
The vital signs are mandatory in this patient as it is a pelvic exam. In the general exam, the mental and nutrition status of the patient must be noted. Additionally, a complete abdominal exam must be conducted as the patient has flank pain and suprapubic tenderness. Palpation of the abdomen for any masses and percussion of the flank for costovertebral angle tenderness must be done (Bono et al., 2022). Similarly, complete respiratory and cardiovascular exams must be conducted as a routine during the assessment of any patient. Finally, a digital rectal examination must be performed to exclude associated rectal abnormalities.
Assessment
In addition to urinalysis, STI, and pap smear testing, a complete blood count and urine culture must be conducted as the patient presents with signs of infection. Similarly, a pregnancy test must be conducted as this may complicate urinary tract infections. Additionally, she has no appetite and therefore a random blood sugar must be done to exclude hypoglycemia. Similarly, urea, creatinine, and electrolyte must be conducted to check the renal function as the patient has flank pain. Finally, Inflammatory markers such as ESR and CRP as well as blood cultures must be done as the patient has flank pain which may indicate pyelonephritis (Bono et al., 2022). Imaging tests are not necessary for the diagnosis of lower UTI. However, the patient has flank pain, and therefore, a CT scan of the abdomen and pelvis with or without IV contrast as well as an ultrasound of the kidneys and bladder must be done to identify any pathologies and outline the architecture of the kidney and bladder (Belyayeva & Jeong, 2022)
The possible diagnoses include a urinary tract infection and a sexually-transmitted infection. Urinary tract infections refer to the infection of the bladder, urethra, ureters, or kidneys (Bono et al., 2022). UTIs are more common in women, a consequence of a short urethra and proximity of the anal and genital regions (Bono et al., 2022). A triad of frequency, dysuria, and urgency collectively defines the irritative lower urinary tract symptoms (Bono et al., 2022). Similarly, suprapubic tenderness is a key feature of lower urinary tract infections. However, the patient is also feverish and has flank pain which also denotes the potential for involvement of the upper urinary tract (Bono et al., 2022). T.S is also sexually active, a risk factor for urinary tract infection.
A sexually transmitted infection is another possible diagnosis. T.S is sexually active and she has had her new partner for the last three months which is a key risk factor for this condition (Garcia & Wray, 2022). Most STIs present with suprapubic pain. Most STIs are asymptomatic and if symptomatic manifests with urethral discharge, vaginal discharge, pruritus, and pain (Garcia & Wray, 2022). T.S was negative for the aforementioned features.
Other differential diagnoses include pyelonephritis, interstitial cystitis, and urethritis due to an STI. Pyelonephritis is of the renal pelvis and parenchyma (Belyayeva & Jeong, 2022). It is usually a complication of ascending bacterial infection of the bladder and manifests principally with frequency, dysuria, urgency, fever, malaise, flank pain, and suprapubic pain (Belyayeva & Jeong, 2022). Interstitial cystitis is a chronic noninfectious idiopathic cystitis associated with recurrent suprapubic pain (Daniels et al., 2018). It presents with urgency, frequency, suprapubic discomfort, and pain relieved by voiding. T.S has some of these features although the gradual onset of symptomatology and a duration of more than six weeks is required for the diagnosis of this condition (Daniels et al., 2018). Finally, urethritis secondary to an STI may present in females with only frequency, urgency, and dysuria with minimal or no vaginal discharge (Young et al., 2022).
Conclusion
Assessment of the genitalia and rectum is sensitive and may help identify abnormalities of the rectum and genitourinary tract. Most abnormalities of the genitourinary system particularly UTIs and STIs can be diagnosed clinically. Consequently, a comprehensive history and physical examination are mandatory. Most UTIs are common in females. Pregnancy must always be excluded in a patient presenting with features suggestive of a UTI.
References
Belyayeva, M., & Jeong, J. M. (2022). Acute Pyelonephritis. https://pubmed.ncbi.nlm.nih.gov/30137822/
Bono, M. J., Leslie, S. W., & Reygaert, W. C. (2022). Urinary Tract Infection. https://pubmed.ncbi.nlm.nih.gov/29261874/
Daniels, A. M., Schulte, A. R., & Herndon, C. M. (2018). Interstitial cystitis: An update on the disease process and treatment. Journal of Pain & Palliative Care Pharmacotherapy, 32(1), 49–58. https://doi.org/10.1080/15360288.2018.1476433
Garcia, M. R., & Wray, A. A. (2022). Sexually Transmitted Infections. https://pubmed.ncbi.nlm.nih.gov/32809643/
Young, A., Toncar, A., & Wray, A. A. (2022). Urethritis. https://pubmed.ncbi.nlm.nih.gov/30725967/
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: Asthma
· Medications: Symbicort 160/4.5mcg
· Allergies: NKDA
· FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD
· Social: 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 169lbs
· Heart: RRR, 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 with a healed episiotomy scar present. 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, neg McBurney
· Diagnostics: HSV specimen obtained
Assessment:
· Chancre
· PLAN: 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.
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
O.
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
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