Sample Answer for NURS 6512 WEEK 10 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum Included After Question
Patients are frequently uncomfortable discussing with health care professionals 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 Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
Case 1: Rectal Bleeding
A 62-year-old male construction worker reports to your clinic after experiencing rectal bleeding for over 1 month. He has noticed small amounts of blood after every bowel movement. He had a colonoscopy 2 years ago with normal results. The patient has no fever, chills, dysuria, abnormal urinary frequency, or abdominal pain. The patient reports occasional rectal itching and pain. He states he has no noticeable sores on his rectal area and no family history of colorectal cancer.
Case 2: Dysuria
A 55-year-old African-American male reports to your clinic complaining of frequent and painful urination for the past 2 months. The patient is sexually active and has been in a monogamous relationship for the past 3 years. He reports no penile discharge, fever, chills, abdominal pain, or back pain. His father is deceased and passed away of colon cancer. His father had a history of benign prostatic hypertrophy (BPH). The patient considers himself as a healthy male. He works for a large American corporation, has a relatively healthy diet, and exercises 4 to 5 times per week.
Case 3: Genitalia
A 21-year-old college student reports to your clinic with external bumps on her genital area. The bumps are painless and feel rough. The patient is sexually active and has had more than one partner over the past year. Her initial sexual contact occurred at age 18. The patient 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 had one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.
To prepare:
With regard to the case study you were assigned:
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 you were assigned.
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.
Note: Before you submit your initial post, replace the subject line (“Week 10 Discussion”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.
By Day 3
Post a description of the health history you would need to collect from the patient in the case study to which you were assigned. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Read a selection of your colleagues’ responses.
By Day 6
Respond to at least two of your colleagues on two different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject, and why. Identify the most likely condition, and justify your reasoning.
A Sample Answer For the Assignment: NURS 6512 WEEK 10 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum
Title: NURS 6512 WEEK 10 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum
The SOAP note depicts RG 30-year-old woman with complaints of dysuria and urinary frequency for three days. She describes the pain as intermittent and experiences a burning sensation only during micturition, but she began having flank pain last night. She had UTI three years ago and a hysterectomy five years ago. Abnormal exam findings include mild fever (100.9), lower quadrant tenderness on palpation, and CVA tenderness. The assessment findings are UTI and STD. The purpose of this assignment is to examine the SOAP note and identify additional patient information that should be included and discuss possible conditions.
Subjective Portion
The HPI has described key elements, including the onset of symptoms, duration, characteristics, associated symptoms, measures taken to alleviate symptoms, and severity of pain. However, it should have also included the characteristics of the flank pain, whether it is constant or radiating and if sharp, dull, or gnawing pain. The severity of the flank pain should also be included. The patient’s immunization history (last Influenza, Tdap, and Covid vaccine) should also be included in the subjective part (Podder et al., 2021). Besides, the sexual history should be included with information on sexual preference, the number of partners, and condom use, since this guide in assessing the risk of STIs. In addition, the review of symptoms (ROS) has only pertinent positives and negatives in the general and abdominal assessment. All other body systems should have been included since it helps to identify symptoms that the patient failed to mention in the HPI.
Objective Portion
The objective part includes only vital signs and abdominal exam findings. The portion should include findings from general, cardiovascular, respiratory, and genitourinary exams. This is a focused genital and rectal exam, and thus, it should include findings from the examination of the pubic hair, clitoris, urethral meatus, vaginal introitus, perineum, and anus (Podder et al., 2021). In addition, it should have findings from special exams like the bimanual exam and vaginal speculum.
Assessment
UTI is supported by the positive patient’s symptoms of dysuria characterized by a burning sensation when urinating, urinary frequency, and flank pain. It is also supported by physical exam findings of mild fever, costovertebral angle (CVA) tenderness, and tenderness in the lower quadrants (Holm et al., 2021). STD is supported by physical findings of mild fever and lower quadrant tenderness.
Diagnostic Tests
The pertinent diagnostic tests for this case include urinalysis, urine culture, and a complete blood count. The urinalysis will be used to confirm or rule out UTI. Urine culture is an essential confirmatory test and can help identify the specific bacterial pathogen causing urinary symptoms and antimicrobial susceptibility of the causative bacteria (Holm et al., 2021). The CBC can rule out infection and identify if the patient has a complicated or uncomplicated UTI.
Differential Diagnoses
UTI is an appropriate diagnosis for this patient since she presents with the disease’s classic symptoms like dysuria, flank pain, urinary frequency, and CVA tenderness. Therefore, I would accept the UTI diagnosis. Nevertheless, I would reject STD because it is not specific, and the patient does not have adequate subjective findings to support the diagnosis. The likely conditions for this case are:
Acute Pyelonephritis: This is a bacterial infection in the kidney and renal pelvis caused by microbes ascending from the urinary tract into the kidney tissue. Clinical features include fever, chills, tachycardia, tachypnea, flank pain, CVA tenderness, abdominal discomfort, nausea, vomiting, general malaise, burning, frequency, or urgency of urination, and nocturia (Song et al., 2022). Many patients usually have a history of recent cystitis or treatment for UTI. Acute pyelonephritis is a differential owing to positive findings of burning sensation on urination, urinary frequency, flank pain, chills, fever, CVA tenderness, and a history of UTI.
UTI: UTI in adults presents with dysuria, urinary urgency and frequency, lower abdominal discomfort, a sensation of bladder fullness, low back pain, CVA tenderness, bloody urine, and suprapubic tenderness. Rare symptoms include nausea, vomiting, fever, chills, malaise, and flank pain (Czajkowski et al., 2021). UTI is a differential based on dysuria, urinary frequency, flank pain, CVA tenderness, lower abdominal tenderness, fever, and chills.
Cystitis: This is characterized by bladder inflammation due to irritation or infection by bacteria, fungi, viruses, or parasites. Typical clinical features include dysuria, urinary frequency, urgency, flank pain, lower abdominal pain, bacteriuria, sensation of incomplete bladder emptying, and urine retention (Kulchavenya, 2018). Cystitis is a likely diagnosis based on positive features of dysuria, urinary frequency, chills, fever, and lower abdominal tenderness.
Conclusion
The subjective portion should describe the flank pain and include immunization history, sexual history, and ROS of all systems. Besides, the objective should include general, cardiovascular, respiratory, and genitourinary assessment findings. The appropriate lab tests for this case are urinalysis, urine culture, and CBC to identify if the patient has UTI and identify the causative organism. The differential diagnoses are acute pyelonephritis, UTI, and cystitis.
References
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
Holm, A., Siersma, V., & Cordoba, G. C. (2021). Diagnosis of urinary tract infection based on symptoms: how are likelihood ratios affected by age? a diagnostic accuracy study. BMJ Open, 11(1), e039871. https://doi.org/10.1136/bmjopen-2020-039871
Kulchavenya, E. (2018). Acute uncomplicated cystitis is antibiotic unavoidable?. Therapeutic Advances in Urology, 10(9), 257–262. https://doi.org/10.1177/1756287218783
Podder, V., Lew, V., & Ghassemzadeh, S. (2021). SOAP notes. In StatPearls [Internet]. StatPearls Publishing.
Song, H. K., Shin, D. H., Na, J. U., Han, S. K., Choi, P. C., & Lee, J. H. (2022). Clinical investigation on acute pyelonephritis without pyuria: a retrospective observational study. Journal of Yeungnam Medical Science, 39(1), 39–45. https://doi.org/10.12701/yujm.2021.01207
A Sample Answer 2 For the Assignment: NURS 6512 WEEK 10 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum
Title: NURS 6512 WEEK 10 Assignment 1: Lab 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. 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.
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/