Assessing the Genitalia and Rectum Assignment
Assessing the Genitalia and Rectum Assignment
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.
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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? Assessing the Genitalia and Rectum Assignment
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.
GENITALIA ASSESSMENT
Assessing the Genitalia and Rectum Assignment
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: Assessing the Genitalia and Rectum Assignment
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.
Assessing the Genitalia and Rectum Assignment
