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Sample Answer for NURS 6521 WEEK 10 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum\u00a0 Included After Question<\/strong><\/em><\/span><\/h2>\n
Patients are frequently uncomfortable discussing with health care professional\u2019s 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.<\/p>\n
In this assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.<\/p>\n
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. NURS 6512 Week 10 Assignment 1: Assessing the Genitalia and Rectum.<\/p>\n
$\"NURS$
NURS 6521 WEEK 10 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum<\/figcaption><\/figure>\n
GENITALIA ASSESSMENT<\/strong><\/h2>\n
Subjective:<\/strong><\/h3>\n
\n
CC: \u201cI have bumps on my bottom that I want to have checked out.\u201d<\/li>\n
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. NURS 6512 Week 10 Assignment 1: Assessing the Genitalia and Rectum.<\/li>\n
PMH: Asthma<\/li>\n
Medications: Symbicort 160\/4.5mcg<\/li>\n
Allergies: NKDA<\/li>\n
FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD<\/li>\n
Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)<\/li>\n<\/ul>\n
Objective:<\/strong><\/h2>\n
\n
VS: Temp 98.6; BP 120\/86; RR 16; P 92; HT 5\u201910\u201d; WT 169lbs<\/li>\n
Heart: RRR, no murmurs<\/li>\n
Lungs: CTA, chest wall symmetrical<\/li>\n
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<\/li>\n
Abd: soft, normoactive bowel sounds, neg rebound, neg murphy\u2019s, neg McBurney<\/li>\n
Diagnostics: HSV specimen obtained<\/li>\n
NURS 6512 Week 10 Assignment 1: Assessing the Genitalia and Rectum<\/li>\n<\/ul>\n
Assessment:<\/strong><\/h2>\n
\n
Chancre<\/li>\n
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.<\/li>\n<\/ul>\n
To prepare:<\/strong><\/h2>\n
With regard to the SOAP note case study provided:<\/p>\n
\n
Review this week\u2019s Learning Resources, and consider the insights they provide about the case study.<\/li>\n
Consider what history would be necessary to collect from the patient in the case study.<\/li>\n
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\u2019s condition. How would the results be used to make a diagnosis?<\/li>\n
Identify\u00a0at least five<\/strong>\u00a0possible conditions that may be considered in a differential diagnosis for the patient.<\/li>\n
NURS 6512 Week 10 Assignment 1: Assessing the Genitalia and Rectum<\/li>\n<\/ul>\n
To complete:<\/strong><\/h2>\n
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.<\/p>\n
\n
Analyze the subjective portion of the note. List additional information that should be included in the documentation.<\/li>\n
Analyze the objective portion of the note. List additional information that should be included in the documentation.<\/li>\n
Is the assessment supported by the subjective and objective information? Why or Why not?<\/li>\n
Would diagnostics be appropriate for this case and how would the results be used to make a diagnosis?<\/li>\n<\/ul>\n
\n
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. NURS 6512 Week 10 Assignment 1: Assessing the Genitalia and Rectum.<\/li>\n<\/ul>\n
A Sample Answer For the Assignment: NURS 6521 WEEK 10 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum\u00a0<\/strong><\/h2>\n
Title: NURS 6521 WEEK 10 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum\u00a0<\/strong><\/h2>\n
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.\u00a0<\/span>\u00a0<\/span><\/p>\n
Subjective Portion<\/span><\/b>\u00a0<\/span><\/h2>\n
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\u2019s 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.\u00a0\u00a0\u00a0<\/span>\u00a0<\/span><\/p>\n
Objective Portion<\/span><\/b>\u00a0<\/span><\/h2>\n
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.\u00a0<\/span>\u00a0<\/span><\/p>\n
Assessment<\/span><\/b>\u00a0<\/span><\/h2>\n
UTI is supported by the positive patient\u2019s 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.<\/span>\u00a0<\/span><\/p>\n
Diagnostic Tests<\/span><\/b>\u00a0<\/span><\/h2>\n
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.\u00a0<\/span>\u00a0<\/span><\/p>\n
Differential Diagnoses<\/span><\/b>\u00a0<\/span><\/h2>\n
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:<\/span>\u00a0<\/span><\/p>\n
Acute Pyelonephritis<\/span><\/b>: 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.\u00a0\u00a0\u00a0\u00a0<\/span>\u00a0<\/span><\/p>\n
UTI: <\/span><\/b>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.\u00a0<\/span>\u00a0<\/span><\/p>\n
Cystitis<\/span><\/b>: 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.\u00a0<\/span>\u00a0<\/span><\/p>\n
Conclusion<\/span><\/b>\u00a0<\/span><\/h2>\n
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.\u00a0<\/span>\u00a0<\/span><\/p>\n
\u00a0<\/span><\/p>\n
References<\/span><\/b>\u00a0<\/span><\/h2>\n
Czajkowski, K., Bro\u015b-Konopielko, M., & Teliga-Czajkowska, J. (2021). Urinary tract infection in women.\u202f<\/span>Przeglad Menopauzalny = Menopause Review<\/span><\/i>,\u202f<\/span>20<\/span><\/i>(1), 40\u201347. https:\/\/doi.org\/10.5114\/pm.2021.105382<\/a><\/span>\u00a0<\/span><\/p>\n
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.\u202f<\/span>BMJ Open<\/span><\/i>,\u202f<\/span>11<\/span><\/i>(1), e039871. https:\/\/doi.org\/10.1136\/bmjopen-2020-039871<\/a><\/span>\u00a0<\/span><\/p>\n
Kulchavenya, E. (2018). Acute uncomplicated cystitis is antibiotic unavoidable?. <\/span>Therapeutic Advances in Urology<\/span><\/i>,\u202f<\/span>10<\/span><\/i>(9), 257\u2013262. https:\/\/doi.org\/10.1177\/1756287218783<\/a><\/span>\u00a0<\/span><\/p>\n
Podder, V., Lew, V., & Ghassemzadeh, S. (2021). SOAP notes. In\u202f<\/span>StatPearls [Internet]<\/span><\/i>. StatPearls Publishing.\u00a0<\/span>\u00a0<\/span><\/p>\n
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.\u202f<\/span>Journal of Yeungnam Medical Science<\/span><\/i>,\u202f<\/span>39<\/span><\/i>(1), 39\u201345. https:\/\/doi.org\/10.12701\/yujm.2021.01207<\/a><\/span>\u00a0<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"
Sample Answer for NURS 6521 WEEK 10 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum\u00a0 Included After Question Patients are frequently uncomfortable discussing with health care professional\u2019s 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 […]<\/p>\n","protected":false},"author":11,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-124890","post","type-post","status-publish","format-standard","hentry","category-nursing-papers"],"blocksy_meta":[],"yoast_head":"\nNURS 6521 WEEK 10 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum \u00a0 - Nursing Assignment Crackers<\/title>\n<meta name=\"description\" content=\"NURS 6521 WEEK 10 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum: Patients are frequently uncomfortable discussing with health care professional\u2019s issues that involve the genitalia and rectum \u00a0\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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