Assignment: Assessing the Genitalia and Rectum

Assignment: Assessing the Genitalia and Rectum

Assignment 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. 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).

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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/

Healthcare practitioners could analyze the rectum and genitalia by thoroughly analyzing the offered subjective and objective data. Analyzing the offered data is necessary in order to get correct findings. In light of this, the purpose of this essay is to investigate the case of T.S., a 32-year-old woman who has been experiencing urgency, frequency, and dysuria for the past two days without treating presenting clinical manifestations.

The submitted objective and subjective data will be examined, examined, and new information will be added in order to make it more detailed. Additionally, pertinent diagnostic tests will be suggested following which it would be possible to state the differential diagnosis (Dains & Scheibel, 2019).

Analysis of Subjective Data

When obtaining subjective data on a patient with genitalia health conditions, an array of information is needed to ensure that one has captured all the relevant details that will help narrow down the possible differential diagnosis to just one. The initial complaint, “Increased frequency and pain with urination,” was a correct presentation of a portion of the history of presenting illness (HPI). The timing ought to be mentioned in the HPI as well; it was reported to have happened two days ago (Dains & Scheibel, 2019).

It is also important to specify the location of the pain, which was identified as being around the genitalia according to the information given. To determine the location, system reviews that focus on the genitourinary system ought to be analyzed. To indicate whether the discomfort is permanent or intermittent, the frequency of the pain should be mentioned in the specifics. In response, the patient said that the pain started when urinating (Dains & Scheibel, 2019).

Information on if the patient sought treatment and the actions taken should be included; in this

instance, the patient declared they did not undergo any kind of medical treatment. Details on whether the patient has ever had symptoms associated with the urgency and frequency should be also be provided. The involvement of the genitalia raises questions regarding the patient’s sexual habits that need to be addressed. In response, the patient said that in the last three months, she had engaged in sexual activity and dated someone new (Dains & Scheibel, 2019).

1. How the patient rates their pain on a scale of 1-10 and also information on how the presenting clinical manifestations have affected her usual daily activities should be provided (Dains & Scheibel, 2019).

2. Information on whether the patient attempted to treat her clinical manifestations at home together with the specific forms of treatment she might have used should be provided (Dains & Scheibel, 2019).

3. Due to the presenting clinical manifestations a system that should be assessed examined is the genital-urinary system and it should be checked whether the patient is experiencing hematuria, nocturia, any swelling and also any changes to the color of urine (Dains & Scheibel, 2019).

4. The gastrointestinal system should also be examined on presence of dullness or masses (Dains & Scheibel, 2019).

5. The patient’s social history should be assessed to find out whether the patient uses illicit drugs, their caffeine intake, whether they are stressed and if they can easily access healthcare. Additionally, information on whether the patient is using any over the counter drugs or has prescription drugs should be obtained together with the frequency and dose (Dains & Scheibel, 2019).

6. Also information on whether the patient had been hospitalized previously should be obtained as it will help in finding out whether thy had any procedures done such as urinary catheterization that could have led to the resenting signs and symptoms (Dains & Scheibel, 2019).

7. The characteristics of the pain the patient experiences should be identified such as whether it is stabbing, burning or itching (Dains & Scheibel, 2019).

It’s crucial to consider past medical history, and in this instance, the patient revealed that he had had tonsillectomy and appendectomy as part of his surgical history. Providing details on a history of STIs (sexually transmitted illnesses) is also crucial. It could be useful to know whether there are any allergies, particularly while giving medication. It is imperative to ascertain whether the patient has had any recent vaccinations. To ascertain whether the patient’s illness is caused by a genetic disorder and if relatives have had a condition similar to their own, family history information should be available (Dains & Scheibel, 2019).

It is also necessary to perform a study of the systems whereby the patient reported to experiencing difficulty sleeping due to flank pain. The patient should state any breathing problems in the respiratory system and any chest pain or edema in the cardiovascular system. The patient did not appear to be vomiting from the abdomen, despite having minimal appetite. The patient’s breasts should be checked at that time, and they should also report if they have ever had a previous breast exam (Dains & Scheibel, 2019).

The examination of the genitourinary system was necessary because it was the source of the signs and symptoms that were described; additionally, one may inquire as to whether the urine smells or whether there is a vaginal discharge. Since the individual in question is female and may require further examination of her reproductive system, asking about the timing of her most recent menstrual period will help exclude out pregnancy as a potential explanation of the symptoms. Given that the patient acknowledged having sex, you can ask about their condom, contraceptive, and STI testing habits. Furthermore, it’s critical to find out whether the patient has undergone a pap smear (Dains & Scheibel, 2019).

Analysis of the Objective Data

The objective data should provide further details on the patient. This covers their overall manner, whether or not their answers to questions were appropriate, their cleanliness, posture, and mood, among other things. Additionally, as the pelvis is linked to the genesis of the exhibiting clinical symptoms, a pelvic examination ought to be carried out (Cheshire & Goldstein, 2018).

Upon exploring the suprapubic area at the time of the pelvic exam, it was discovered that the uterus and adnexa were pain-free and in good condition. The cervix is normal, and there is no vaginal discharge. The vital signs were within normal range, with one notable exception of the temperature, that read 37.3 degrees Celsius and would suggest a minor illness (Ball, et al., 2015).

1. The patient’s general appearance should be examined (Ball, et al., 2015).

2.  Examination of the various systems such as abdominal region, cardiovascular, skin, respiratory and genital urinary would be necessary as these systems would provide relevant information to related to the presenting clinical manifestations (Cheshire & Goldstein, 2018).

Analysis of the Assessment

The assessment is supported by both subjective and quantitative evidence. The patient had mentioned before to having the same clinical symptoms. The patient took no action that would have relieved the symptoms when they returned. Moreover, there was a correlation between the pain and both urgency and frequency. All of this confirms the principal complaint of the patient, which indicated a condition of the genitourinary system. The mentioned differentials are also relevant since the patient’s symptoms are consistent with these conditions since they affect the genitourinary system (Dains & Scheibel, 2019).

Recommended Diagnostic Tests

In order to determine the condition, the patient is suffering from there are diagnostics test to be carried out that include:

1. Complete blood count (CBC) – this is done find out the number of white blood cells and if elevated determine if there is an infection causing the resulting clinical manifestations (Ball, et al., 2015).

2. Pregnancy test –  this is because if one is pregnant symptoms of a UTI could worsen hence explaining the resulting clinical manifestations (Ball, et al., 2015).

3. Urinalysis- this is done to examine renal function and aid rule out conditions such as pyelonephritis that could be causing the presenting clinical manifestations (Ball, et al., 2015).

4. Abdominal CT scan-  this is due to the presenting clinical manifestation of flank pain hence the scan is done to find out whether there are any abnormalities in the abdominal region (Ball, et al., 2015)

5. Pap smear-conducting this test can help rule out a condition such as herpes simplex virus (HSV) that could be causing the presenting clinical manifestations (Ball, et al., 2015).

Possible Differential Diagnosis

The two possible diagnoses for this patient are could be either an STI or an UTI. Women are more prone to UTIs than men are because of their shorter urethra and the close proximity of the vaginal and anal regions. Three symptoms, urgency, frequency, and dysuria, characterize a disorder in the lower urinary tract. Suprapubic discomfort is a common symptom of upper urinary tract infections. On the other hand, the patient’s flank pain and fever point to an upper urinary tract issue (Bono, et al., 2022).

An illness acquired through sexual contact is an additional possibility. The patient is sexually active, which is an additional risk factor for this disorder. She has been dating her new boyfriend for three months. Suprapubic discomfort is caused by most STIs. Sexually transmitted infections (STDs) can cause discomfort, vaginal discharge, and urethral discharge, even though the majority of them are asymptomatic (Garcia & Wray, 2022).

  1. Cystitis- this illness causes inflammation of the bladder, mainly in women. Because the patient had previously reported experiencing similar symptoms, it is possible that mild cases resolved on their own. It appears with dysuria, frequency and urgency in the same way that the patient experienced them. These parallels make it feasible to conclude that the virus has resurfaced (McCance & Huether, 2019).

2. Pyelonephritis- in this condition there is damage to the parenchyma and renal pelvis, when damage occurs in these areas it results in the clinical manifestations the patient is presenting with thus it being a possible diagnosis (McCance & Huether, 2019).

 3. Bacterial vaginosis-  this is a condition whereby bacteria invades the human body causing clinical manifestations of itching and burning similar to what the patient is presenting with thus it being a likely diagnosis (Garcia & Wray, 2022).

4. Urethritis- this is an inflammation in the urethra whereby women present with frequency, urgency and dysuria similar to what the patient is presenting with thus it being a likely diagnosis (Bono, et al., 2022).

5. Yeast infection – this condition presents with clinical manifestations of burning, a discharge and itching due to a fungal infection similar to what the patient is presenting with thus it being a likely diagnosis (Garcia & Wray, 2022).

Conclusion

To identify anomalies of the genitourinary tract and rectum, a comprehensive examination of the genitalia and rectum might be utilized. The majority of genitourinary illnesses, including STIs and UTIs, can be identified clinically. Consequently, a complete physical examination and medical history are required. Most incidences of UTIs occur in women. From the moment a patient presents with UTI symptoms, pregnancy needs to be ruled out (Dains & Scheibel, 2019).

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. Case Study Assignment:    Assessment Tools and Diagnostic Tests in Adults and Children

Bono, M. J., Leslie, S. W., & Reygaert, W. C. (2022). Urinary Tract Infection.             https://pubmed.ncbi.nlm.nih.gov/29261874/

Cheshire, W. P., & Goldstein, D. S. (2018). The physical examination as a window into    autonomic disorders. Clinical Autonomic Research, 28(1), 23-33.

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.

Garcia, M. R., & Wray, A. A. (2022). Sexually Transmitted Infections.             https://pubmed.ncbi.nlm.nih.gov/32809643/

McCance, K. L., Huether, S. E., BRASHERS, V. L., & ROTE, N. S. (2019). Pathophysiology:    The biologic basic for diseases in adults and children (No. ed. 8). Elsevier.

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.

RESOURCES

Learning Resources

Note: To access this week’s required library resources, please click on the link t