NURS 6512 Assignment Assessing The Genitalia And Rectum

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.

Health assessment is essential for doctors to develop effective care plans. This involves analyzing available data, using clinical reasoning, diagnosing the patient, and determining appropriate therapy. It is crucial to take into account the patient’s subjective information and the findings of any diagnostic tests while doing a genitourinary examination (Chen & Zeng, 2019). The case study reports that a 32-year-old woman presented with symptoms of increased frequency, painful urination, and a strong urge to urinate over the past 48 hours. A thorough health assessment is crucial for formulating an efficient treatment strategy, as it facilitates a more profound comprehension of the patient’s state. This paper aims to explore the necessity of incorporating supplementary subjective and objective data to enhance the diagnosis of the patient.

Additional Subjective Information

The client’s main concern is experiencing increased frequency, discomfort, and urgency in urination. To enhance the understanding of the client’s main issue, only the time of symptom onset and location have been communicated using the acronym “OLD CARTS” (Chen & Zeng, 2019). The patient’s experience with the aforementioned symptoms throughout the previous two days is the basis for this information. The allergies and prior medical history (PMH) of the client are not well described. The patient’s incomplete vaccination history is crucial for determining the source of their illness and determining the most effective treatment. Accurate assessment of a client’s risk factors for specific medical conditions necessitates a comprehensive evaluation of their family and social history. Additionally, there is a lack of information in the client’s medical records concerning her maintenance of health, including her eating and sleeping patterns, as well as her reproductive history, including her menstrual cycle.

Additional Objective Information

Healthcare practitioners get objective information relevant to the patient’s main complaint during a physical examination. In assessing the patient’s general state of health, the practitioner should look for indicators of alertness, weariness, or excellent grooming. Obtaining the patient’s height and weight data is crucial for calculating their body mass index (BMI) and determining their optimal body weight (Chen & Zeng, 2019). Even if her vital signs are there, there is still a lack of this specific information. Since problems in these systems are linked to weakened health and heightened susceptibility to infections, cardiovascular and pulmonary tests are required to evaluate the functioning of these systems. Furthermore, the presence of symptoms related to genitourinary illnesses necessitates a comprehensive assessment of the genitourinary system. The adnexal region showed modest soreness, the suprapubic area likewise showed mild tenderness, and there was no vaginal discharge.

Assessment

The subjective and objective data strongly align with the patient’s assessment, suggesting the presence of a possible urinary tract infection (UTI). The patient presents with symptoms indicative of a UTI, including heightened frequency, urgency, and dysuria, based on their subjective medical history. Holm et al. (2021) identified cloudy and malodorous urine as additional symptoms of UTI. However, the client’s objective history indicates slight suprapubic discomfort, potentially resulting from urinary retention, which could be indicative of an infection. Urine tests and culture remain necessary to substantiate this assertion.

Diagnostics Appropriateness

Healthcare practitioners need precise diagnostic procedures to effectively detect genitourinary disorders since many of these ailments have symptoms of increasing urgency and frequency. Urinalysis is one test done to find out whether any bacteria, viruses, or other microbes might be the cause of the illness (Holm et al., 2021). A urine culture is necessary to determine the specific bacteria responsible for the infection. Cystoscopy is necessary for the evaluation of urinary tract infections to identify their underlying cause.

Differential Diagnosis

With the data that has been provided, including symptoms like increased frequency, dysuria, and urgency that lasts for two day, I agree with the current diagnosis of UTI (Holm et al., 2021). Findings from the physical examination, including moderate suprapubic discomfort, might point to an infection. Urine analysis and culture should be performed to rule out other possible diseases and confirm the diagnosis. The symptoms stated may be diagnosed as urethritis, pelvic inflammatory disease (PID), vaginitis, pyelonephritis, or painful bladder syndrome. Itching, drainage, and pain are some of the symptoms of vaginitis. Its incidence is often attributed to infections or changes in vaginal flora (Kaur & Kaur, 2020). UTI pyelonephritis, often referred to as kidney infection, starts in the bladder or urethra and then spreads to the kidneys (Kolman, 2019). The female reproductive system is impacted by pelvic inflammatory disease, or PID (Curry et al., 2019). Bacteria that spread via sexual contact may go from the genitalia to the fallopian tubes, uterus, or ovaries. Frequency, urgency, and dysuria are the hallmarks of painful bladder syndrome; an infection is not present. The absence of bacteriuria and the presence of pyuria are characteristics of urethritis. Women who engage in sexual activity run a higher risk.

Conclusion

The female patient exhibits symptoms of heightened frequency, dysuria, and urgency upon arrival at the clinic. This disorder is often associated with symptoms such as reduced appetite, stomach pain, and pelvic discomfort. The observed indications and symptoms suggest a possible diagnosis of UTI, but additional subjective as well as objective information is required to substantiate this conclusion. To confirm the initial diagnosis and exclude alternative diseases, additional diagnostic tests were necessary.

References

Chen, J., & Zeng, R. (2019). Frequency, Urgency, and Dysuria. Handbook of Clinical Diagnostics, 75–76. https://doi.org/10.1007/978-981-13-7677-1_24

Curry, A., Williams, T., & Penny, M. L. (2019). Pelvic Inflammatory Disease: Diagnosis, Management, and Prevention. American Family Physician, 100(6), 357–364. https://www.aafp.org/pubs/afp/issues/2019/0915/p357.html?utm_medium=email&utm_source=transaction

Holm, A., Siersma, V., & Cordoba, G. C. (2021). Diagnosis of urinary tract infection based on symptoms: how are likelihood ratios affected by age? A diagnostic accuracy study. BMJ Open, 11(1), e039871. https://doi.org/10.1136/bmjopen-2020-039871

Kaur, R., & Kaur, R. (2020). Symptoms, risk factors, diagnosis, and treatment of urinary tract infections. Postgraduate Medical Journal, 97(1154), postgradmedj-2020-139090. https://doi.org/10.1136/postgradmedj-2020-139090

Kolman, K. B. (2019). Cystitis and Pyelonephritis. Primary Care: Clinics in Office Practice, 46(2), 191–202. https://doi.org/10.1016/j.pop.2019.01.001