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.

Lab Assignment: Assessing the Genitalia and Rectum

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.

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

Lab Assignment: Assessing the Genitalia and Rectum Instructions

Please be mindful of plagiarism and APA format, I have included the rubric. Please use my course resources as one of my references as instructed. Please include 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 as one of the references

Learning Resources

Required Readings (click to expand/reduce)

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.

Chapter 17, Breasts and Axillae”

This chapter focuses on examining the breasts and axillae. The authors describe the examination procedures and the anatomy and physiology of breasts.

Chapter 19, “Female Genitalia”

In this chapter, the authors explain how to conduct an examination of female genitalia. The chapter also describes the form and function of female genitalia.

Chapter 20, “Male Genitalia”

The authors explain the biology of the penis, testicles, epididymides, scrotum, prostate gland, and seminal vesicles. Additionally, the chapter explains how to perform an exam of these areas.

Chapter 21, “Anus, Rectum, and Prostate”

This chapter focuses on performing an exam of the anus, rectum, and prostate. The authors also explain the anatomy and physiology of the anus, rectum, and prostate.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 5, “Amenorrhea”

Amenorrhea, or the absence of menstruation, is the focus of this chapter. The authors include key questions to ask patients when taking histories and explain what to look for in the physical exam.

Chapter 6, “Breast Lumps and Nipple Discharge”

This chapter focuses on the important topic of breast lumps and nipple discharge. Because breast cancer is the most common type of cancer in women, it is important to get an accurate diagnosis. Information in the chapter includes key questions to ask and what to look for in the physical exam.

Chapter 7, “Breast Pain”

Determining the cause of breast pain can be difficult. This chapter examines how to determine the likely cause of the pain through diagnostic tests, physical examination, and careful analysis of a patient’s health history.

Chapter 27, “Penile Discharge”

The focus of this chapter is on how to diagnose the causes of penile discharge. The authors include specific questions to ask when gathering a patient’s history to narrow down the likely diagnosis. They also give advice on performing a focused physical exam.

Chapter 36, “Vaginal Bleeding”

In this chapter, the causes of vaginal bleeding are explored. The authors focus on symptoms outside the regular menstrual cycle. The authors discuss key questions to ask the patient as well as specific physical examination procedures and laboratory studies that may be useful in reaching a diagnosis.

Chapter 37, “Vaginal Discharge and Itching”

This chapter examines the process of identifying causes of vaginal discharge and itching. The authors include questions on the characteristics of the discharge, the possibility of the issues being the result of a sexually transmitted infection, and how often the discharge occurs. A chart highlights potential diagnoses based on patient history, physical findings, and diagnostic studies.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

Chapter 3, \”SOAP Notes\” (Previously read in Week 8)
Mealey, K., Braverman, P. K., & Koenigs, L. M. (2019). Why a pelvic exam is needed to diagnose cervicitis and pelvic inflammatory disease. Annals of Emergency Medicine, 73(4), 424–425. https://doi.org/10.1016/j.annemergmed.2018.11.028

Sanchez, C., Israel, R., Hughes, C., & Gorman, N. (2019). Well-woman examinations: Beyond cervical cancer screening. The Journal for Nurse Practitioners, 15(2), 189–194.e2. https://doi.org/10.1016/j.nurpra.2018.09.005

Centers for Disease Control and Prevention. (2021, April 13). Sexually transmitted disease surveillance, 2019. https://www.cdc.gov/std/#

This section of the CDC website provides a range of information on sexually transmitted diseases (STDs). The website includes reports on STDs, related projects and initiatives, treatment information, and program tools.

Document: Final Exam Review (Word document)

Optional Resource

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical.

Chapter 8, “The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts” (Section 2, “The Breasts,” pp. 380-390)

Section 2 of this chapter focuses on the anatomy and physiology of breasts. The section provides descriptions of breast examinations and common breast conditions.
Chapter 11, “The Female Genitalia and Reproductive System”

In this chapter, the authors provide an overview of the female reproductive system. The authors also describe symptoms of disorders in the reproductive system.
Chapter 12, “The Male Genitalia and Reproductive System”

The authors of this chapter detail the anatomy of the male reproductive system. Additionally, the authors describe how to conduct an exam of the male reproductive system.
Review of Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid”
Required Media (click to expand/reduce)

Special Examinations – Breast, Genital, Prostate, and Rectal – Week 10 (14m)

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Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum

Photo Credit: Getty Images

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.

The assignment for this week is an analysis of a SOAP note for the genitalia/rectum. As in the previous SOAP note analysis, this should be completed in a narrative format and answer all the questions listed in the assignment within the module. Please remember to use the rubric to complete the assignment.

Genitourinary Assessment:

Subjective:

CC: Increased frequency and pain with urination

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

Review of Systems:

General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.

Abdominal: Denies nausea and vomiting. No appetite

Objective

VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.

Pelvic Exam:

mild tenderness to palpation in the suprapubic area

bimanual pelvic examination reveals a normal-sized uterus and adnexae

no adnexal tenderness.

No vaginal discharge is noted.

The cervix appears normal.

Diagnostics:

Urinalysis

STI testing

Papsmear

Assessment:

UTI

STI

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.