Assessing the Genitalia and Rectum Essay Assignment Example
Assessing the Genitalia and Rectum Essay Assignment Example
Assessing the Genitalia and Rectum
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.
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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. Assessing the Genitalia and Rectum Essay Assignment Example.
• 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. Assessing the Genitalia and Rectum Essay Assignment Example.
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. Assessing the Genitalia and Rectum Essay Assignment Example.
Introduction
For clients who present with genitourinary symptoms, it is necessary that a focused and comprehensive history is taken followed by a thorough examination. Genitourinary problems are likely to trigger issues in other systems of the body. Similarly, difficulties that may arise in the various systems are likely to affect the quality of life and overall well-being of a client. Clinical nursing skills should possibly result in a list of the potential differential diagnoses and the definite diagnosis. With this approach, it is certain that a clinician will focus on the most appropriate tests that can confirm the diagnosis. This paper is an extensive discussion of the additional subjective and objective data that should be included in the assessment of clients presenting with genitourinary problems. A description of the use of diagnostics in making a diagnosis and possible differential diagnoses will also be provided. Assessing the Genitalia and Rectum Essay Assignment Example.
Additional Subjective Data to Include in the documentation.
The client will be asked to provide more information about additional symptoms associated with the bumps as I examine them to determine the color, pattern, size, and shape. The client will also be asked whether the bumps have appeared for the first time or they have also been there in the past, exact period and any previous medications used to manage them. It would also be necessary to ascertain and document if the client has noticed the bumps somewhere else in the body other than the genitals. According to Dains, Baumann & Scheibel (2016), general symptoms of a patient may relate to other systems within the body and produced by pathologies in the genitourinary tract. Information on associated symptoms such as a skin rash, recent weight loss, loss of hair, a fever, sores on the anus, dysuria, fatigue, and muscle aches should be documented alongside their relieving and aggravating factors is vital. The client will also be asked about the use of douches, fragrant and soaps and to rate the extent at which they are a bother to her general life on a scale of 0-10. Assessing the Genitalia and Rectum Essay Assignment Example.
Under the past medical and surgical history, past histories of genital herpes and other STIs apart from chlamydia should be documented. She will also be asked about the medications that were prescribed for chlamydia and by whom. The client should reveal if she has any skin conditions, psoriasis or eczema. The client’s full course of immunization, the age of asthma diagnosis and progress with its management should also be documented (Dains, Baumann & Scheibel, 2016). Previous female surgeries are also a vital part of the documentation.
It is also necessary that the client’s gynecological history is taken. Gynecological history includes the menstrual history where frequency, duration, volume, date of last menstrual period, contraception use and HIV is documented. The menstrual history will help to eliminate any possibilities of a pregnancy before further assessments and management (Jensen, 2018). Still, on gynecological history, information about post-coital-bleeding, dyspareunia, and vulval itching should also be included. Post-coital bleeding and dyspareunia are symptoms of sexually transmitted illnesses. Assessing the Genitalia and Rectum Essay Assignment Example.
The client should also be asked if she performs self-breast exams. On the sexual history, it would be necessary to document the client’s preferences of her sexual practices and if she has unprotected sex, anal sex, the specific number of sexual partners, how often she has sex and if she knows the status of her sexual partners. Her last sexual episode/encounter should be documented as this will help to approximate the duration it took for symptoms to present and possibly the definitive diagnosis.
The client is evidently married and a mother to 1 girl and 2 boys. Therefore, it would be essential to take her obstetric history. An obstetrics history provides a clinician with vital clues to the client’s health risks. Previous congenital malformations which may result from STIs may indicate a predisposition to other STIs (Jensen, 2018). The client’s occupational history is very significant. An occupation that predisposes one to sexual encounters increases their risk for sexually transmitted illnesses which should be comprehensively addressed in the management to prevent STI risks in the future. Assessing the Genitalia and Rectum Essay Assignment Example.
Additional Objective Data to Include In the documentation.
It would be necessary to document the overall cleanliness, grooming, affect and stature of the client. On the HEENT exam, the throat should be assessed for redness, drainage, edema, enlarged tonsils, cold sores, lesions, and oral thrush to check for the systemic infection with HSV or other viruses. The documentation of the neck exam should include nodal tenderness, enlarged cervical nodes, jugular venous distension and goiters (Seidel, et al., 2015). In the Chest exam, the client should be assessed for non-labored breathing, enlargement of axillary nodes, discharge, and tenderness over the nipples. Chest retractions and nasal flaring should be assessed and documented. Assessing the Genitalia and Rectum Essay Assignment Example.
In the CVS assessment, documentation about any pedal or general body edema and peripheral pulses should be included. In the genito-urinary exam, it would be mandatory to inspect the cervix and do a pap smear. The cervix will also be assessed for motion tenderness and general cervical tenderness. During this exam, signs of vaginal bleeding and foul-smelling vaginal discharge will be noted and documented. Palpation and documentation for inguinal tenderness and lymphadenopathy, whether the ulcer is the only one, indurated and its color should also be included (Seidel, et al., 2015). A rectal exam to ascertain any lesions, hemorrhoids, masses, and trauma will be necessary. A detailed skin exam to assess for pink color, warmth, and dryness will be included. Other areas with redness, lesions, and scarring, discoloration and patches will be examined and documented. Assessing the Genitalia and Rectum Essay Assignment Example.
Whether the Assessment Is Supported By Subjective and Objective Data
The assessment concluded that the client had a Chancre. A chancre often presents in veneral disease and it usually develops over the genital area. More specifically, in females, chancres can also present over the vagina, anus or the vulva and take between 3 weeks to 3 months to present after infection. The chancre is often a painless ulcer, highly infectious and forms in the primary stage of syphilis which is a sexually transmitted illness (Dains, Baumann & Scheibel, 2016). Similarly, according to the subjective data, the client reportedly noticed a painless and rough lump over her genital area and reported no vaginal discharge. The client also agreed that she was sexually active and had had more than one partner in a year which increases her risk of a sexually transmitted infection. Based on the objective data, it was ascertained that the client had a round, small painless ulcer on the external labia. However, the abdominal examination and other examinations were normal. It is also due to the painless ulcer that an HSV specimen was taken for diagnostics. Therefore, the assessment of a chancre is correctly supported by both the objective and subjective data. Assessing the Genitalia and Rectum Essay Assignment Example.
The relevance of Diagnostics and Its Use to Make a Diagnosis
The diagnostics, in this case, was a HSV specimen which was taken for viral culture. In most cases, the results of a culture take between 1 to 7 days. Polymerase Chain Reaction can also be done to test for herpes simplex antibodies to confirm the diagnosis of herpes simplex (Dains, Baumann & Scheibel, 2016). Possibly, a tzanck smear can be done using the base of the vesicle which is also definitive for herpes simplex. In the findings, multinucleated giant cells may be found in case the samples would be taken from a herpes lesion that is intact. According to Dains, Baumann & Scheibel (2016), a serology test in the forms of VDRL, RPR or a non-treponemal pallidum test would be done to rule out syphilis. To rule out Chlamydia and Gonorrhea, rapid Nucleic Acid Amplification tests would be the most recommended (Tao, et al., 2017).
View on the Current Diagnosis
Primary syphilis often presents with a chancre which is a form of ulcer lesion that develops at the inoculation site. It often starts off a papule and gradually develops into a painless, firm, indurated ulcer (Wolujewicz & Bates, 2016). Most clients cannot be aware as it presents no symptoms and the ulcer often heals on itself within 3-6 weeks. The ulcerative lesions usually appear exactly 2 weeks following exposure. Syphilis can be confirmed through serology as it is also supported by the subjective and objective data. Assessing the Genitalia and Rectum Essay Assignment Example.
Possible Differential Diagnoses
The most potential differential diagnoses, in this case, include syphilis, herpes simplex II and acute contact dermatitis. Basing on the fact that the client had multiple sexual partners within a year, she is at a potential risk of syphilis whose diagnosis can be confirmed with a serological test. To add on, by the lesion being located on the labia, it allows for contact directly with a syphilis sore (Wolujewicz & Bates, 2016). Besides, the patient reported that the ulcer was painless with no itchiness or burning prior to the eruption, this is an indication of syphilis. The client’s subjective and objective data also supports syphilis as a potential differential diagnosis but not without further history taking and diagnostics. To ascertain the possibilities of syphilis, extensive data & information on the lesion borders, clarity of its base and how central it is would be vital.
The likelihood of Herpes progenitalis also referred to as Herpes Simplex II is high. However, the presence of a single ulcer limits this possibility since superficial vesicles can either be eroded or not. Depending on the client’s description of the ulcer, it was firm. In herpes simplex II, while primary infections are extensive, recurrent infections are often localized yet patchy with several lesions (Dains, Baumann & Scheibel, 2016). Besides, the lesions are not only painful but can result in a burning sensation with urination. Assessing the Genitalia and Rectum Essay Assignment Example.
Although the differential diagnosis of acute contact dermatitis is unlikely since the client presents with no history of topical allergens, it is possible. The history of the client’s recent activities in terms of contact with caustic chemicals and garden work may support this differential. However, if the sore could be contact related the erythema regions would be large. Assessing the Genitalia and Rectum Essay Assignment Example.
References
Dains, J. E., Baumann, L. C., & Scheibel, P., (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Jensen, S. (2018). Nursing health assessment: A best practice approach. Lippincott Williams & Wilkins.
Seidel, H.M., Ball, J. S., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidels’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Tao, G., Hoover, K. W., Nye, M. B., Peters, P. J., Gift, T. L., & Body, B. A. (2017). Infrequent testing of women for rectal chlamydia and gonorrhea in the United States. Clinical Infectious Diseases, 66(4), 570-575.
Wolujewicz, A., & Bates, C. (2016). Syphilis on the face in primary care: a rare sign of an increasingly common problem. The British Journal of General Practice, 66(648), e528–e530. Assessing the Genitalia and Rectum Essay Assignment Example.
