Feb 23, 2024 LAB ASSIGNMENT: ASSESSING THE GENITALIA AND RECTUM
LAB ASSIGNMENT: ASSESSING THE GENITALIA AND RECTUM
LAB ASSIGNMENT ASSESSING THE GENITALIA AND RECTUM
Assessing the Genitalia and Rectum
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. In the subsequent paragraphs, potential history, physical exam, and differential diagnosis shall be explored 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.
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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
LAB ASSIGNMENT ASSESSING THE GENITALIA AND RECTUM
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/
Advance Nursing Assessment and Diagnostic Reasoning
Human papillomavirus (HPV) is one of the most common sexually transmitted infections among late teens and young adults. In the year 2018, approximately 43 million cases of HPV were reported in the United States. Studies show that there are over 100 varieties of HPV (Breznik et al., 2020). Some cases of HPV can cause warts, while others have been associated with different types of cancer. The infection is also associated with other complications such as oral and upper respiratory lesions.
To prevent the spread of the infection among populations at high risks, the CDC recommends two doses of the Gardasil 9 vaccine for both males and females at ages 11 and 12. Routine screening is also recommended among sexually active individuals for early detection of the infection and treatment. The diagnosis of the disorder involves pap tests, DNA tests, and acetic acid solution tests. There is no cure for the disease. However, individuals can benefit from treatment options available for symptomatic relief. This paper demonstrates the assessment and diagnosis of a 21-year-old female patient with a chief complaint of bumps on her bottoms, and medical history of chlamydia, which was diagnosed about 2 years before the present visit.
Subjective Data
The information provided by the patient is quite limited to making a definitive diagnosis. The patient is unaware of when the bumps started appearing on her bottom but confirms having multiple sexual partners. Additionally, she confirms a history of chlamydia. This information only provides a clue of what the patient is suffering from but cannot be conclusively used in determining the cause of the patient’s symptoms. Additional subjective data such as associated symptoms, characteristics of the bumps on her bottom, and the spread of the bumps to other body parts are missing (Pfennig, 2019).
Consequently, the patient must also state whether she has noticed any changes in the size and number of the bumps, ever since she first noticed them. She also needs to provide information regarding any use of medication for her current symptoms, and whether they have been helpful or not. It is also very important for the patient to provide substantial information regarding her reproductive history such as the use of birth control pills, and her menses, for further evaluation of her condition.
Objective Data
Building upon the subjective data, the physical examination of the patient will be focused on her chief complaint. Objective data such as the patient vital signs, in addition to an examination of her heart, genitalia, abdomen, and lungs have been clearly outlined. However, a general evaluation of the patient’s health must also be conducted to find out additional symptoms such as fatigue, sleeping problems, and weight changes, to be able to determine the severity of her condition. Additionally, with a primary diagnosis of the chancre, the patient should have been screened for different types of cancer, such as rectal cancer which is mostly associated with the disorder (Jain, Patil, & Karnavat, 2020).
The reported genitourinary examination is also missing important factors such as the menstrual pattern of the patient, which might have been affected by the patient’s condition. Additional information such as vaginal bleeding or painful sex should have also been evaluated to rule out other possible causes of the patient’s symptoms such as chlamydia or gonorrhea. The only diagnostic test obtained is the HSV specimen. However, additional tests such as scraping tests for spirochetes, urinalysis for UTI, gonorrhea, and chlamydia, Tzanck smear test for herpes virus, and acetic acid tests for HPV lesions should also be ordered to rule out the respective differential diagnosis.
Assessment
The assessment for chancre is not fully supported by the provided subjective and objective data. Chancre is described as a painless genital ulcer that normally occurs during the primary stage of syphilis. As such, the subjective and objective data should have been focused on determining other symptoms of syphilis. On the contrary, the patient only reported bumps on her bottom, a history of chlamydia, and multiple sexual partners, which do not conclusively suggest chancre (Poteat, Harbatkin, & Light, 2019).
To support this assessment, the subjective portion of the patient information should have described the bump as firm and round, rather than just painless. The objective data, on the other hand, is even less supportive, as physical examination of the patient’s genitalia revealed no swellings or masses. The diagnostic tests ordered are also for HSV and not for syphilis or chancre.
Diagnostics
Based on the subjective and objective data provided for the patient, it is quite difficult to make a definitive diagnosis. Several diagnostic tests must however be ordered to determine the primary medical condition affecting the patient. For instance, lab works such as HSV viral culture for lesion test, which normally takes 7 days, must be ordered to rule out HSV as the cause of the patient’s symptoms.
Nucleic acid amplification tests should also be ordered to find out whether the patient’s symptoms are a result of gonorrhea or chlamydia. Pelvic examination in addition to KOH wet mount and pH test of the patient’s vaginal discharge is also necessary to help detect the presence of fungal or bacterial infections such as UTI (Jain et al., 2021). To rule out spirochetes, an acetic acid test must be ordered to identify subclinical lesions from HPV Scraping. Before making a diagnosis of syphilis, it is necessary to obtain a positive EIA test, confirmed with either RPR or VDRL tests. Imaging studies such as pelvic x-ray and CT scans may also help visualize anatomical deformities such as abnormal proliferation of cells to rule out cervical cancer among other genital cancers.
Primary Diagnosis
The patient’s primary diagnosis of chancre is wrong. Despite the patient’s symptoms suggesting this diagnosis, additional tests necessary to confirm the presence of chancre are missing (Poteat et al., 2019). Given that chancre normally presents in the primary stage of syphilis, stage-specific diagnostic tests such as darkfield microscopy or nontreponemal tests are required to confirm this diagnosis.
Differential Diagnosis
Looking at the provided patient history, the main differential diagnosis is anal warts (condyloma acuminata), genital herpes simplex, and molluscum contagiosum. Anal warts are a form of genital warts which normally result from human papillomavirus (HPV). This condition is usually characterized by small painless warts inside or around the anus. It is mostly diagnosed through visual examination (Jain et al., 2021).
The provided patient history of painless bumps on her bottom, with a history of chlamydia, and multiple sexual partners support the diagnosis of HPV, leading to anal warts. Genital herpes simplex is also associated with bumps or blisters, but is painful, making this diagnosis inappropriate. Molluscum contagiosum is also associated with painless bumps but spreads on the whole body rather than being localized in one area.
References
Breznik, V., Fujs Komloš, K., Hošnjak, L., Luzar, B., Kavalar, R., Miljković, J., & Poljak, M. (2020). Determination of causative human papillomavirus type in tissue specimens of common warts based on estimated viral loads. Frontiers in cellular and infection microbiology, 10, 4. https://doi.org/10.3389/fcimb.2020.00004
Jain, R. S., Behere, R. V., Patil, P. A., & Karnavat, D. R. (2021). Study of Warts affects the Humans with their signs and symptoms. Asian Journal of Pharmaceutical Research, 11(1). DOI: 10.5958/2231-5691.2021.00013.7
Jain, R. S., Patil, P. A., & Karnavat, D. R. (2020). Identification of different types of Wart affect the Human Body. Asian Journal of Research in Pharmaceutical Science, 10(1), 31-34. DOI: 10.5958/2231-5659.2020.00007.7
Pfennig, C. L. (2019). Sexually transmitted diseases in the emergency department. Emergency Medicine Clinics, 37(2), 165-192. https://doi.org/10.1016/j.emc.2019.01.001
Poteat, T., Harbatkin, D., & Light, A. D. (2019). Sexual Health for Women. The GLMA Handbook on LGBT Health [2 volumes], 229.
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
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 Nursi
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