Special Examinations—Breast, Genital, Prostate, and Rectal

Special Examinations—Breast, Genital, Prostate, and Rectal

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Evaluate abnormal findings on the genitalia and rectum
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the breasts, genitalia, prostate, and rectum


This week you will have an analysis of a SOAP note.  It is important to remember that this is not to be in SOAP note format.  This should be a narrative paper. 



Here is the case that you will base this on:

GENITALIA ASSESSMENT
Subjective:
CC: dysuria and urinary frequency
HPI: RG is a 30 year old female with increase urinary frequency and dysuria that began 3 days ago. Pain is intermittent and described a burning only in urination, but c/o flank pain since last night. Reports intermittent chills and fever. Used Tylenol for pain with no relief. She rates her pain 6/10 on urination. Reports a similar episode 3 years ago.
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
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

Patients are frequently uncomfortable discussing with healthcare 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 Lab Assignment, you will analyze an Episodic 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.
To Prepare
Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
Based on the Episodic note case study:
Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.
Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
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.
The Lab Assignment
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.

Rubric Points: With regard to the SOAP note case study provided and 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?·  
 What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?·   Would you reject or accept the current diagnosis? Why or why not?
·   Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.		

Assessing the Genitalia and Rectum Sample Approach

Subjective Portion Analysis

When dealing with subjective information, the goal is to make certain that one asks all of the pertinent questions in order to compile all of the information they need in order to arrive at a definitive diagnosis and devise a productive therapy strategy. The knowledge of any known allergies or other intolerances that their clients may have must be continually sought out by clinicians. Some additional features that should be included in the subjective data include:

• Information on the pain, including when it began, where it was located what it was, how it shifted over time, and if it was spreading.
• Urine appearance and smell.
• The frequency, recurrence, or consistency of the symptoms.
• Blood or discharge from the vagina.
• Pregnant and gynecological history.
• Whether there is a risk of exposure to hazardous chemicals.
• The family’s medical history.

Objective Portion Analysis

It is essential to carry out a detailed physical examination after gathering an exhaustive medical history in regard to the principal complaint. The vital indicators will be updated to include her heart rate shortly. The patient’s physical examination may be made better by providing any extra information that would be helpful in making a diagnosis of the condition being experienced by the patient. Additionally, diagnostic tests and their findings should be included in the objective portion. The general survey has to be included as well, and it needs to cover the patient’s overall look, cleanliness, attire, and any facial grimacing that may be present.

Whether the assessment is supported by the subjective and objective information

Although the subjective and objective information are lacking some details, the assessment of the patient of having UTI and STD is a very strong possibility. On the episodic note, the patient was having dysuria and urinary frequency, now with intermittent fever and chills. Despite the absence of some information in both the subjective and objective reports, the likelihood of the client having a UTI or an STD is quite high. According to the SOAP note, the client was experiencing urination frequency and dysuria, and she was also feeling chills and fever intermittently. It is noted in the objective section of the note that a urine test in addition to an STD test was carried out. On the other hand, the findings of the tests that were performed on the objective part of the note were not provided.

Diagnostic Tests

In order to verify a diagnosis or eliminate possible causes, diagnostic testing is essential. In accordance with the provided SOAP note, the symptoms of an STD and a UTI are very comparable to one another. Therefore, diagnostic testing will assist in determining which of the two conditions the patient suffers from (Behzadi, et al., 2019). A urinalysis test should be ordered, in which the following components of the urine are analyzed: the pH level, bacterial STIs, red blood cells, epithelial cells, protein, white blood cells, nitrite, the presence of glucose, and ketones, and the specific gravity. In addition, I will include testing for hepatitis C, a complete STD panel, and HIV.

Differential diagnosis

The diagnosis of a urinary tract infection is one that I am willing to accept. There was sufficient evidence in the SOAP note to lead me to the conclusion that the patient had a urinary tract infection (UTI), despite the fact that the information it included was both restricted and inadequate. Individuals who have a urinary tract infection often exhibit a number of symptoms, including dysuria, flank pain, urine frequency and urgency, chills, and fevers. Another potential alternative diagnosis that I will consider is a pelvic inflammatory disease. It is a condition that affects the upper part of the female genital tract and is characterized by infection and inflammation. Females who do not utilize birth control and have a history of having several sexual partners are considered to be greatly at risk of UTI (Behzadi, et al., 2019). Among the signs and symptoms include acute discomfort in the pelvis and lower abdomen, a low-grade fever, nausea, and vomiting (Mayo Clinic, 2018). Acute Pyelonephritis is another potential diagnosis. It is a bacterial infection of the kidney tissues that often originates in the lower urinary system and progresses upwards (Belyayeva & Jeong, 2019). Hematuria, fever, discomfort at the costovertebral joint, vomiting, or nausea are some of the symptoms.

                                                                 

 

                                                                  References

Behzadi, P., Behzadi, E., & Pawlak-Adamska, E. A. (2019). Urinary tract infections (UTIs) or genital tract infections (GTIs)? It’s the diagnostics that count. GMS hygiene and infection control, 14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6449866/

Belyayeva, M., & Jeong, J. M. (2019). Acute pyelonephritis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519537/

 Mayo Clinic. (2018). Pelvic inflammatory disease (PID) – Symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/pelvicinflammatory-disease/symptoms-causes/syc-20352594