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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.
This is the case study for the assignment
Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum
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:
o 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.
o Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
o Consider what history would be necessary to collect from the patient in the case study.
o 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?
o 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.
This is SOAP note documentation using the above template
Expert Solution Preview
Introduction:
In this assignment, we will analyze an episodic note case study that describes abnormal findings in patients seen in a clinical setting. We will consider what history should be collected from the patient, as well as which physical exams and diagnostic tests should be conducted. Furthermore, we will formulate a differential diagnosis with several possible conditions.
1. What additional information should be included in the subjective portion of the note?
In the subjective portion of the note, the patient’s past medical history (PMH) and family history (FHx) are mentioned, along with her presenting symptoms. However, additional information that should be included in the subjective portion of the note includes the onset, duration, and progression of the patient’s symptoms, as well as any other symptoms she may be experiencing apart from dysuria and urinary frequency.
2. What additional information should be included in the objective portion of the note?
In the objective portion of the note, the patient’s vital signs and abdominal exam findings are mentioned, along with diagnostic tests being performed. However, additional information that should be included in the objective portion of the note includes a thorough genitalia and rectal exam, as well as any other relevant physical exam findings. Furthermore, it would be helpful to document the results of the urine specimen collected and STD testing.
3. Is the assessment supported by the subjective and objective information? Why or why not?
Yes, the assessment of UTI and STD are supported by the subjective and objective information. The subjective information (patient history and presenting symptoms) supports the presence of a UTI, and the objective information (abdominal exam and urine specimen collected) further supports this diagnosis. Additionally, the presence of STD symptoms supports the assessment of an STD.
4. Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
Yes, diagnostics such as urine culture and sensitivity testing and STD testing were already performed and are appropriate for this case. The results of these diagnostic tests would aid in determining the appropriate treatment plan for the patient.
5. 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.
I would accept the current diagnosis of UTI and STD based on the subjective and objective information provided. However, other possible conditions that may be considered in a differential diagnosis include acute pyelonephritis, interstitial cystitis, and kidney stones.
According to Nicolle (2018), acute pyelonephritis is a urinary tract infection that has reached the patient’s kidneys and manifests with fever, chills, and flank pain. Interstitial cystitis, as described by Hanno et al. (2011), is a chronic bladder condition that can cause urinary frequency and dysuria. Kidney stones, as noted by Sas et al. (2019), can cause flank pain and urinary symptoms. It is essential to note that further examination and testing would be required to differentiate between these conditions.
#Normal #false #false #false #ENUS #XNONE #GENITALIA #ASSESSMENT
