Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum Essay

Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum Essay

Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum Essay

Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum Sample Essay

Health assessment is crucial in facilitating doctors’ ability to develop optimal care plans by utilizing available data, clinical reasoning, patient diagnosis, and therapy. When conducting a genitourinary examination for a client, it is important to consider the subjective data and diagnostic test results provided by the patient (Chen & Zeng, 2020). According to the case study, a 32-year-old female presented with complaints of frequency, dysuria, and urgency for the past two days. A comprehensive health evaluation is essential for developing an effective treatment plan, as it provides a deeper understanding of the patient’s condition. The purpose of this paper is to investigate the need for additional subjective and objective data to further the diagnosis of this patient.

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Additional Subjective Information

            The client’s subjective information includes increased urine frequency, discomfort, and urgency as the primary concern. To further clarify the client’s primary concern, only the time of onset and location of the symptoms have been provided using the acronym “OLD CARTS.” This information is based on the patient’s experience of the mentioned symptoms over the past two days (Kim et al., 2019). The client’s allergies and past medical history (PMH) are not adequately specified (Chen & Zeng, 2020). Relevant subjective data includes an appendectomy performed in 2020 and a tonsillectomy performed in 2001. The vaccination history of the patient is lacking, which is essential for diagnosing the origin of the patient’s disease and establishing the optimal therapy. It is impossible to estimate the client’s risk factors for certain medical diseases without a full family and social history. Furthermore, there are incomplete records regarding the client’s reproductive history, such as her menstrual cycle, as well as insufficient information about her health maintenance practices, such as eating and sleeping habits (Eleutério et al., 2023). Finally, the patient’s system review is also inadequate.

Additional Objective Information

During a physical examination, objective data is typically collected, focusing primarily on facts that are relevant to the patient’s main complaint. The physician should initially evaluate the patient’s overall health by observing their general demeanor, including signs of attentiveness, fatigue, or good grooming (Kim et al., 2019). To assess the patient’s optimal body weight and calculate their BMI, it is necessary to obtain their height and weight information. Despite the availability of her vital signs, there is still a lack of this specific information. Cardiovascular and pulmonary tests are required to examine the functionality of both systems since anomalies in both systems are linked with poor health and heightened susceptibility to infection. In addition, given the existence of genitourinary illness symptoms, a thorough evaluation of the genitourinary system is required. In addition to the absence of vaginal discharge and slight tenderness in the adnexal region, there was also mild tenderness reported in the suprapubic area. The pelvic bimanual examination revealed normal sizes and appearance of the patient’s adnexa, uterus, and cervix. To enhance our understanding of the patient’s illness, it would have been beneficial to obtain information regarding the visual and olfactory properties of the patient’s urine (Charvériat & Fritel, 2019). To provide an appropriate diagnosis, the choice of diagnostic tests must be based on the available objective data.

Assessment

The subjective and objective data largely support the patient’s assessment, indicating a potential urinary tract infection (UTI). The patient reports experiencing symptoms consistent with a UTI, including increased frequency, urgency, and pain during urination, as per their subjective medical history. Additional symptoms of UTI include cloudy urine and malodorous urine (Eleutério et al., 2023). In contrast, the client’s objective history suggests minor suprapubic discomfort perhaps caused by urinary retention, which might indicate an infection. Urine tests and culture are still required to support this claim.

Diagnostics Appropriateness

            Due to the shared symptoms of increased urgency and frequency among many genitourinary diseases, healthcare professionals require specific diagnostic tests to accurately diagnose these conditions. One examination conducted is a urinalysis to detect the presence of bacteria, viruses, or other microorganisms that may be causing the condition (Kim et al., 2019). A urine culture is required to identify the exact bacteria causing the disease. Urinary tract infections must be evaluated using cystoscopy to pinpoint their cause.

Differential Diagnosis

            Based on the presented evidence, which includes symptoms such as increasing frequency, dysuria, and urgency persisting for two days, I concur with the current diagnosis of a urinary tract infection (UTI). Physical examination findings, such as mild suprapubic pain, may indicate the presence of an infection. To confirm the diagnosis and exclude other potential diagnoses, I would recommend conducting a urine analysis and urine culture (Ernstsen et al., 2022). Potential diagnoses for the symptoms mentioned include vaginitis, pyelonephritis, pelvic inflammatory disease (PID), Painful Bladder Syndrome, and urethritis.

• Vaginitis is characterized by symptoms such as discomfort, itching, and discharge. Infections or alterations in vaginal flora often contribute to its occurrence. Urinary discomfort is reported (Eleutério et al., 2023). The Amsel criteria for diagnosing vaginitis consist of the following indicators: the presence of clue cells on vaginal fluid microscopy, a pH level exceeding 4.5, the presence of creamy discharge, and a positive result on the sniff test.
• Pyelonephritis, also known as kidney infection, is a urinary tract infection (UTI) that begins in the bladder or urethra and subsequently extends to the kidneys (Ernstsen et al., 2022). According to the case study, this ailment is marked by symptoms including frequent urination, pain while urinating, fever, tiredness, nausea, and vomiting. Evaluation of the symptoms, coupled with a urinalysis or culture, is necessary for the diagnosis.
• PID, or pelvic inflammatory disease, affects the female reproductive organs. Sexually transmitted bacteria can migrate from the genitals to the uterus, fallopian tubes, or ovaries (Charvériat & Fritel, 2019). The case study patient, who is sexually active and has recently changed sexual partners, is at risk of contracting this illness. This condition is characterized by symptoms such as dysuria, dyspareunia, nausea, vomiting, fever, chills, irregular menstruation, and abnormal vaginal discharge. The presence of endometritis histopathology in an endometrial sample confirms the diagnosis of pelvic inflammatory disease (PID). Transvaginal sonography and pelvic magnetic resonance imaging may be necessary for this diagnosis.
• Painful bladder syndrome is characterized by symptoms such as frequency, urgency, and dysuria, without the presence of infection (pyuria, bacteriuria, positive urine cultures). It is usually diagnosed through a process of elimination (Ball et al., 2019).
• Urethritis is characterized by the presence of pyuria without the presence of bacteriuria. According to Ball et al. (2019), sexually active women are at increased risk.

Conclusion

The female patient presents at the clinic with symptoms of increased frequency, dysuria, and urgency. Symptoms such as decreased appetite, abdominal discomfort, and pelvic discomfort are commonly observed in association with this condition. The observed indications and symptoms point to a potential UTI diagnosis, but further subjective and objective information is needed to support this conclusion. To validate the original diagnosis and rule out other possible diseases, several diagnostic tests were also required. Urine culture, pelvic ultrasound, and urine testing are a few examples of diagnostic techniques. PID, pyelonephritis, painful bladder disease, urethritis, and vaginitis are the primary diagnoses that may be made in the differential diagnosis.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby

Charvériat, A., & Fritel, X. (2019). Diagnosis of pelvic inflammatory disease: clinical, paraclinical, imaging, and laparoscopy criteria. CNGOF and SPILF pelvic inflammatory diseases guidelines. Gynecologie, Obstetrique, Fertilite & Senologie, 47(5), 404-408. DOI: 10.1016/j.gofs.2019.03.010

Chen, J., & Zeng, R. (2020). Frequency, Urgency, and Dysuria. In Handbook of Clinical Diagnostics (pp. 75-76). Springer, Singapore. https://doi.org/10.1007/978-981-13-7677-1_24

Eleutério, J., Campaner, A. B., & de Carvalho, N. S. (2023). Diagnosis and treatment of infectious vaginitis: Proposal for a new algorithm. Frontiers in Medicine, 10. https://doi.org/10.3389/fmed.2023.1040072

Ernstsen, C. V., Login, F. H., Schelde, A.-S. B., Therkildesen, J. R., Jakob Møller-Jensen, Rikke Nørregaard, Praetorius, H. A., & Nejsum, L. N. (2022). Acute pyelonephritis: Increased plasma membrane targeting of renal aquaporin‐2. 234(2). https://doi.org/10.1111/apha.13760‌

Kim, W. B., Lee, S. W., Lee, K. W., Kim, J. M., Kim, Y. H., & Kim, M. E. (2019). How Women Evaluate Syndromic Recurrent Urinary Tract Infections. Urogenital Tract Infection, 14(2), 46-54. https://doi.org/10.14777/uti.2019.14.2.46

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GENITALIA ASSESSMENT

Subjective:

• CC: dysuria and urinary frequency

HPI: T.S. is a 32-year-old woman who reports that for the past two days, she has dysuria, frequency, and urgency. Has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months.

Medical History:

None

Surgical History:

• Tonsillectomy in 2001
• Appendectomy in 2020

• PMH: UTI 3 years ago
• PSHx: Hysterectomy at 25 years
• Medication: Tylenol 1000 mg PO every 6 hours for pain
• FHx: Mother breast cancer ( alive) Father hypertension (alive)
• Social: Single, no tobacco , works as a bartender, positive for ETOH
• Allergies: PCN and Sulfa
• LMP: N/A

Review of Symptoms:

• General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
• Abdominal: Denies nausea and vomiting. No appetite

Objective:

• VS: Temp 100.9; BP: 136/80; RR 18; HT 6’.0”; WT 135lbs
• Abdominal: Bowel sounds present x 4. Palpation pain in both lower quadrants. CVA tenderness
• Diagnostics: Urine specimen collected, STD testing

Assessment:

• UTI
• STD

Medications:

1 tablet Centrum Multivitamin Daily .

Protonix 20mg PO daily for GERD.

These findings, describe abnormal findings and as a provider develop an episodic note and you are allowed to make up vital signs and related body systems areas for the SOAP note.

Using evidence-based resources from your search, 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 three different references from current evidence-based literature.
• 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.