Assignment 1: 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 assessment 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 assessment and diagnostic assessment should be conducted. You will also formulate a differential diagnosis with several possible conditions.

To Prepare

• Based      on the Episodic note case study:
  • Review       this weeks 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 assessment and diagnostic procedure would be appropriate to       gather more information about the patients 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.

CASE STUDY Below

Genitourinary Assessment

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

Pelvic assessment:

• 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 examination, 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.

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.

Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.