Assignment: Lab Assignment: Assessing the Genitalia and Rectum NURS 6512N-32
Lab Assignment: Assessing the Genitalia and Rectum
The SOAP note portrays a 21-year-old White female patient presenting with external bumps on her genital area. She describes the bumps as painless and rough but denies having abnormal vaginal discharge. The 21-year old patient tells the assessor that about 24 months ago, she suffered from chlamydia, which was managed using medication. This paper analyzes the SOAP note’s subjective, objective, and assessment portion and discusses the differential diagnoses.
Subjective Portion
Additional information needed in the HPI includes condoms use and the medication the patient used in treating chlamydia. The PMH should include information on the age the patient was diagnosed with asthma and history of the last asthma attack and hospitalization due to asthma. Additional information is required on the allergies the patient has that trigger asthma attacks. The social history needs to encompass information regarding cultural practices, hobbies, sleeping patterns, diet, exercise, health promotion exercises, employment as well as educational level. Furthermore, the subjective portion should include immunization status, surgical history, and reproductive health history. Moreover, there is a need to include a review of systems (ROS), which entails both positive and negative symptoms in the genitourinary, gastrointestinal, cardiovascular, respiratory, and general systems.
Objective Portion
The objective section of the SOAP Note for this patient should have encompassed information on the general physical examination. This includes information on dressing and grooming, general health status, mood, speech, posture, gait, eye contact, and speech. Since it is a focused exam of the genitalia and rectum, information should be provided on speculum examination, bimanual examination, and rectal exam findings.
Assessment
The identified differential is chancre. According to Roett (2020), chancre characterizes a type of ulcer that is painless and has a spotless base and indurated margin. In the case at hand, the chancre is supported by the objective and subjective outcomes of the medical history of the patient entailing rough bumps seen on the outer parts of the genitalia, which are painless. The chancre differential is supported by the outcomes of the assessment that revealed a hard, tiny, round, and painless ulcer on the outer parts of the labia.
Diagnostics
Diagnostics are essential for this case scenario to help determine the causative agent of the genital ulcer. A genital ulcer is a common manifestation in various STIs, including
HSV infection, chancroid, syphilis, granuloma inguinale, and lymphogranuloma venereum (Maliyar et al., 2019). There are various suggested diagnostic tests for the case such as HSV type-specific serology and the polymerase chain reaction testing. Serologic testing is needed to rule out syphilis and culture for H. ducreyi to rule out chancroid (Maliyar et al., 2019).In addition, genital swabs or bubo aspirate can be tested for C. trachomatis by different tests such as direct immunofluorescence, nucleic acid amplification or culture, to disqualify lymphogranuloma venereum.
Differential Diagnoses
The chancre is an expression that portrays a definite ulcer of the genital and not a medical diagnosis. As such, it is appropriate to decline the existing chancre diagnosis because it is not deemed as a medical diagnosis term. Essentially, the conditions that may be deemed as differential diagnoses comprise:
Herpes simplex virus (HSV) infection
There are numerous early symptoms of the HSV infection such as several painless vesicular lacerations on the labia, vagina, foreskin, or rectum. According to Roett (2020), these vesicles habitually split impulsively and develop into sore, shallow ulcers. Prodromal symptoms often occur before the ulceration, including a mild tingling sensation or sharp pain in the hips, buttocks, or legs (Roett, 2020). Genital HSV is a differential diagnosis based on findings of painless rough external genital bumps and the presence of a hard, round, small, painless ulcer on the outer labia.
Primary Syphilis
The primary syphilis is majorly manifested through a painless ulcer that has a spotless base and indurated margin. Primary syphilis typically presents with solitary lesions, but multiple lesions can occur (O’Byrne& MacPherson, 2019). Infected persons may develop unilateral or bilateral painless, non-suppurative inguinal adenopathy after the appearance of the chancre (O’Byrne& MacPherson, 2019). The medical assessment outcomes that are associated with primary syphilis include the patient’s history of irregular peripheral bumps and the discovery of solid, tiny, and painless ulcers located on the labia’s exterior. In addition, the patient admitted to having many sexual partners in the past, which makes her susceptible to STIs like syphilis.
Chancroid
Chancroid is characterized by painful and non-indurated ulcer of the genital and a friable base and a serpiginous margin. Lautenschlager et al., (2017) noted that genital ulcers build upon the penis’s prepuce and frenulum in the male gender while in female, it builds up the cervix or vulva. In addition, infected persons have tender, suppurative, unilateral inguinal lymphadenopathy (Lautenschlager et al., 2017). Chancroid is a differential diagnosis depending on the existence of an ulcer of the genital on the labia’s exterior. However, the patient’s ulcer is painless, making it a less likely primary diagnosis.
Conclusion
The subjective portion should include additional information on contraceptive use, history of asthma, surgical, reproductive history, social history, and ROS. On the other hand, the objective portion needs to comprise the outcomes from the general assessment, rectal, bimanual, and speculum assessments. It is recommended to conduct diagnostics to confirm or refute lymphogranuloma venereum, HSV infection, granuloma inguinale, syphilis, and chancroid. The possible differential diagnoses include HSV infection, syphilis, and chancroid.
Assignment: Lab Assignment: Assessing the Genitalia and Rectum
Patients are frequently uncomfortable discussing with healthcare professionals issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam is 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 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.
By Day 7 of Week 10
Submit your Assignment.
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Click on the Submit button to complete your submission.
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)
Cucci, E., Santoro, A., DiGesu, C., DiCerce, R., & Sallustio, G. (2015).
Sclerosing adenosis of the breast: Report of two cases and review of the
literature. Polish Journal of Radiology, 80, 122–127.
doi:10.12659/PJR.892706. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4356184/
Sabbagh , C., Mauvis, F., Vecten, A., Ainseba, N., Cosse, C., Diouf, M., &
Regimbeau, J. M. (2014). What is the best position for analyzing the lower
and middle rectum and sphincter function in a digital rectal examination? A
randomized, controlled study in men. Digestive and Liver Disease, 46(12),
1082–1085. doi:10.1016/j.dld.2014.08.045
Westhoff , C. L., Jones, H. E., & Guiahi, M. (2011). Do new guidelines and
technology make the routine pelvic examination obsolete? Journal of
Women’s Health, 20(1), 5–10.
This article describes the benefits of new technology and
guidelines for pelvic exams. The authors also detail which
guidelines and technology may become obsolete.
Centers for Disease Control and Prevention. (2019). Sexually transmitted
diseases (STDs). Retrieved from http://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. (2014). DeGowin’s
diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
Chapter 8, “The Chest: Chest Wall, Pulmonary, and Cardiovascular
Systems; The Breasts” (Section 2, “The Breasts,” pp. 434–444)
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” (pp.
541–562)
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” (pp. 563–584)
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”
(pp. 445–527)
Required Media (click to expand/reduce)
Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with
the course text, Seidel’s Guide to Physical Examination. Focus on the videos and
animations in Chapters 16 and 18–20 that relate to special examinations,
including breast, genital, prostate, and rectal. Refer to the Week 4 Learning
Resources area for access instructions on https://evolve.elsevier.com/
