Last Updated on October 28, 2022 by Admin
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:
- 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.
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 during 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.
• PMH: Asthma
• Medications: Symbicort 160/4.
• 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. 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, negMcBurney
Diagnostics: HSV specimen obtained
Assessment: Chancre
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.
Expert Answer and Explanation
Assessing the Genitalia and Rectum
Information that Should be included in the Subjective Data
The nurse in charge of the patient has included relevant information when assessing the patient subjectively. However, the patient failed to include the OTC medication used by the patient to reduce the symptoms of the condition. The nurse should have been more specific when highlighting the medicine; the patient was using. In the social history section, the patient could have mentioned the spirituality level of the patient. Information about spirituality can be used during the treatment plan. Vaccination and immunization information should have been included in the patient medical history. The patient should have been asked if she can remember what caused the bumps. This information can help the nurse determine the cause of the condition. Lastly, the nurse should have included information about when last the patient had sex.
Information that Should be included in the Objective Data
The nurse has highlighted most of the information in the physical assessment. However, the caregiver has not the heart rate vital for the patient. Assessing the heart rate can help the patient determine the health of the patient’s heart. Also, the objective data should have explained whether the patient experiences nausea, vomiting, eye problem, hearing issues, and throat sickness. The patient’s psychiatric state should also be included in the objective data. In other words, the nurse should determine how the medical condition has affected him psychologically. Overall, the care provider has covered almost all data in this part.
Justification of the Assessment
The care provider responsible for the patient recommended Chancre as the disease affecting the patient. According to de Oliveira et al. (2020), Chancre is a genital ulcer that shows days after a patient has been infected by a bacterium known as Treponema pallidum, a germ that causes syphilis. The assessment is supported by subjective data. According to Donateli et al. (2019), Chancre is a painless disease. This information supported the patient when she said that she does not feel any pain. However, objective information does not support the assessment. The caregiver has not produced the results of the laboratory test, and this has made it hard to recommend the assessment based on objective information.
Importance of Diagnostics
Diagnostics will be so vital in this case because the patient has not given the caregiver adequate information to produce accurate information. The patient gave very few details to work with, and the physical examination did not provide any viable data. Thus, diagnostic information would be significant in this case in that it would be used to determine the actual disease ailing the patient. Donateli et al. (2019) mention that diagnostic results from the lad tests are more accurate and reliable than subjective assessment and physical examination. Also, the process would be vital when recommending medication for the patient.
Differential Diagnoses
I would accept the current diagnosis because the patient does not feel any pain, and this is the key symptom of the mentioned disease. Another diagnosis for this case may be syphilis. According to Liu et al. (2017), syphilis can cause bumps in its primary stage. Another diagnosis may be chancroid. Chancroid can also cause ulcerated lesions on one’s genitals. Herpes can also be a diagnosis for the condition because it also causes a genital ulcer (Watts et al., 2016). The last disease that can cause ulcers is candidiasis.
References
de Oliveira, D., Rosa, L. D., Serrão, B. B. P., de Oliveira, J. B. R., da Paz, A. P. C., da Silva, R. D. S., … & dos Reis, H. L. B. (2020). Rollet’s mixed chancre in Brazilian pregnant women: An unusual case report. International Journal of Infectious Diseases, 91, 57-59. https://www.sciencedirect.com/science/article/pii/S1201971219304503
Donateli, L. R., Barbosa, B. P., Tosato, N. B., Jacomele, J. C., Oliveira, D. M., & Dos, H. R. (2019). Rollet’s mixed chancre in Brazilian pregnant women: An unusual case report. International journal of infectious diseases: IJID: official publication of the International Society for Infectious Diseases. https://europepmc.org/article/med/31743797
Liu, X. K., Wang, Z. S., & Li, J. (2017). Kissing chancre of primary syphilis. IDCases, 7, 38. doi: 10.1016/j.idcr.2016.12.004
Watts, P. J., Greenberg, H. L., & Khachemoune, A. (2016). Unusual primary syphilis: Presentation of a likely case with a review of the stages of acquired syphilis, its differential diagnoses, management, and current recommendations. International journal of dermatology, 55(7), 714-728. https://doi.org/10.1111/ijd.13206
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