Lab Assignment: Assessing the Genitalia and Rectum
Subjective and objective data help healthcare providers to diagnose patients accurately. Focused health history, physical examination, and additional diagnostic tests pertinent to the presenting symptoms help the healthcare provider accurately diagnose and treat patients. This essay focuses on subjective and objective data and diagnostic tests for a patient with genitourinary symptoms.
Additional Subjective Information to Include in the Documentation
The nurse should also ask about associated symptoms such as nausea, loss of appetite, vomiting, and abdominal distention (feeling full). The nurse should ask for any pain and other disorders, such as bleeding during intercourse, now that she reports she is sexually active.
The nurses should also ask for the color of the urine and any odor from the urine: they can ask for or inspect it (Ball et al., 2019). More subjective information should include the amount of fluid intake and the frequency. Data on the last menstrual period and characteristics of the menses is also important.
Additional Objective Information to Include in the Documentation
The nurses should assess the abdomen for any color changes on the flanks and engorged veins and determine the type of pain (tenderness, rebound tenders, crushing, or sharp) and any guarding (Ball et al., 2019). The nurse should observe the vulva and vagina mucosa for any redness secondary to inflammation and record the characteristics of the mucosa. The nurse should also inspect the urethral opening for any lesions and adequacy. Assessment of the back and extremities for edema (common in infections involving the kidneys) is vital.
Assessment Support by the Subjective and Objective Information
The subjective and objective data support the assessment. UTIs and STIs. The patient presented with pain micturition and increased frequency of urination. According to Kolman (2019), most sexually transmitted infections, such as gonorrhea and chlamydia, can cause urinary tract symptoms infections. Pain on micturition is caused by the inflammation of the vulval mucosa and subsequent exposure to acidic urine.
The urethra also gets inflamed, and the membrane is corroded. In some instances, pus and debris accumulate in the urethra hence pain due to blockage of the urethra and exposure of the cells to acidic urine. When the infection spreads to the bladder, there can be increased frequency due to bladder irritation and lower abdominal pain (Kolman et al., 2019).
Further spread of the infections to the ureter and the kidneys. Infection of the kidneys causes flank pain and changes in urine, such as changes in volume and frequency and hematuria. Flank pain also results from inflammation of the kidneys, and the patient has flank discoloration on physical examination. The spread of infections into the cervix and vagina can also lead to lower abdominal pain. The patient presents with flank pain and lower abdominal tenderness, which support the assessment.
Additional Diagnostic Tests
WBC differentials to diagnose any infection or inflammation and predict the microorganisms involved, if any
Renal ultrasonography due to the flank penal to determine the degree of kidney infection and its severity
Pelvic US/CT to diagnose any abnormalities
Full hemogram to diagnose systemic involvement
Blood culture and sensitivity to determine the involved microorganism and effective management of the patient.
Primary Diagnosis: Pyelonephritis
Pyelonephritis is an inflammatory disease that presents primarily with flank tenderness and fever. The patient also presents with hematuria, pus in the urine, abdominal tenderness, urgent or frequent urination, fatigue, and cloudy and smelly urine. The disease is caused by a systemic bacterial infection or ascension of bacteria through the urethra to the kidneys (Johnson & Russo, 2018).
E. coli is the most notorious bacteria leading to extensive kidney damage, hence acute renal injury. Belyayeva and Jeong (2022) note that pyelonephritis often follows a sexually transmitted infection or a urinary tract infection. Pyelonephritis can also result from recurrent UTIs which remain untreated. This case study’s client patient presents with similar symptoms as those in pyelonephritis, and thus it is the primary diagnosis.
Differential Diagnosis #1: Urethritis
Urethritis is the inflammation of the urethra, which causes pain during urination and increases frequency/ urgency, primarily due to intentional retention due to painful micturition. The condition also causes urethral opening irritation and abnormal vaginal discharge.
Sarier and Kukul (2019) note that the severity of the condition and presenting symptoms depend on the microorganisms. Localized urethritis does not cause other symptoms, such as flank and suprapubic pain. The patient presents with symptoms such as flank pain and suprapubic pain that rule out the diagnosis.
Differential Diagnosis #2: Vulvovaginitis
Vulvovaginitis is the inflammation of the vulva and vagina mucosa. The most common symptom of vulvovaginitis is a burning sensation in the vagina, vagina itchiness and pain urinating, pain during intercourse, burning when urinating, and a white, grey, or yellow vagina discharge with a foul smell (Brown & Drexler, 2020). Vagina spotting or bleeding due to inflammation is also common.
The spread of infection to other structures, such as the cervix, uterus, and fallopian tubes, can cause severe suprapubic pain. However, the patient in the case study does have no vaginal discharge. In addition, the patients with vulvovaginitis do not present with flank pain. Hence, the patient does not present with vulvovaginitis.
Differential Diagnosis #3 Pelvic inflammatory disease
Pelvic inflammatory disease is caused by diffuse infection to the reproductive organs. Jennings and Krywko (2019) note that the condition has multiple etiologies, and sexually transmitted infections that ascend to the uterus, fallopian tubes, and ovaries are the most common etiology. The condition presents with lower abdominal/ suprapubic pain, vagina discharge and bleeding, painful intercourse, fever, pain, and difficulty urinating.
The patient presents with similar presentations as PID, but the flank pain rules out the condition. The suprapubic pain is mild in this client but lower abdominal/suprapubic pain is severe in PID (Jennings & Krywko, 2022). Understanding the disease presentations and most notable symptoms helps accurately diagnose a patient. Accurate diagnosis translates into better patient outcomes and health.
Lab Assignment: Assessing the Genitalia and Rectum NURS 6512 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
Belyayeva, M., & Jeong, J. M. (2022). Acute Pyelonephritis. StatPearls [Internet].
Brown, H., & Drexler, M. (2020). Improving the diagnosis of vulvovaginitis: perspectives to align practice, guidelines, and awareness. Population Health Management, 23(S1), S-3. https://doi.org/10.1089/pop.2020.0265
Jennings, L. K., & Krywko, D. M. (2022). Pelvic inflammatory disease. In StatPearls [Internet]. StatPearls Publishing.
Johnson, J. R., & Russo, T. A. (2018). Acute pyelonephritis in adults. New England Journal of Medicine, 378(1), 48-59. https://doi.org/10.1056/nejmcp1702758
Kolman, K. B. (2019). Cystitis and pyelonephritis: diagnosis, treatment, and prevention. Primary Care: Clinics in Office Practice, 46(2), 191-202. https://doi.org/10.1016/j.pop.2019.01.001
Sarier, M., & Kukul, E. (2019). Classification of non-gonococcal urethritis: a review. International Urology And Nephrology, 51(6), 901-907. https://doi.org/10.1007/s11255-019-02140-2
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