NURS 6512 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum
NURS 6512 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum
NURS 6512 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum
Background
The client, T.S., is a 32-year-old woman who presented with dysuria, frequency, and urgency to the clinic. She denies using anything to ease the discomfort. The client reports that these symptoms have persisted for the past year. She discloses having a new partner for the last three months and being sexually active. This paper analyzes the subjective portion, the objective portion of the note, how subjective and objective information supports the assessment, appropriate diagnostics, and rejection/acceptance of the current diagnosis.
The Subjective Portion Analysis and Additional Information
The presented subjective data include dysuria, frequency, and urgency, which have persisted for the past year. These symptoms characterize urinary tract infection (UTI). However, additional information is required to confirm the client’s condition. First, the client’s history of STDs or previous UTI occurrences should be included in subjective data. Furthermore, the subjective portion should capture information regarding using protection during sexual intercourse and experiencing pain or discomfort during intercourse. Finally, informations about any discharge or blood spots should be documented to guide inappropriate diagnosis and treatment.
The Objective Portion Analysis and Additional Information
The objective data indicates mild tenderness to palpation in the client’s suprapubic region, no adnexal tenderness, a normal-sized uterus and adnexa, no vaginal discharge, and a normal cervix. However, additional objective data is needed to assist in the client’s diagnosis and treatment. First, the presence or absence of blood in the urine should be included in the objective portion. Furthermore, the healthcare professional should evaluate the color and smell of the client’s urine. Finally, details of chills/fever should be documented.
Does the Subjective and Objective Information Support Client’s Assessment
The client’s assessment is urinary tract infection (UTI). UTI in women is mainly characterized by fever, a persistent
Assignment 1 Lab Assignment Assessing the Genitalia and Rectum
and strong urge to urinate, chills, a burning sensation when urinating, foul-smelling and cloudy urine, and pelvic pain (Gupta et al., 2017). The client reports these symptoms, including dysuria, frequency, and urgency, persisted for the past year. Therefore, the presented subjective data supports the client’s assessment of urinary tract infection. Additionally, objective data, including suprapubic or pelvic pain on palpation, cloudy or foul-smelling urine, bloody urine, or bleeding of the inflamed bladder wall, characterize UTIs in women (Flores-Mireles et al., 2019). The client’s object data indicates mild tenderness to palpation in the suprapubic area, supporting her assessment of urinary tract infection.
Appropriate Diagnostics
In addition to subjective and objective data, diagnostics would be needed to make the client’s diagnosis. The first diagnostic is a urine culture . The presence of uropathogen in urine cultures is a definitive UTI diagnostic test. Additionally, a urinalysis or urine dipstick should be performed to assess pyuria. The presence of pyuria in this client indicates that she has UTI. According to Beahm et al. (2017), pyuria in urine dipstick or a significant volume of uropathogen in a urine culture indicates UTI. STD tests should also be performed. Positive results for STDs indicate sexually transmitted UTIs. A CT scan should also be used to identify pyelonephritis or abscesses. The presence of pyelonephritis or abscesses indicates UTI. Finally, ultrasonography should be done due to its extreme sensitivity in detecting obstruction, tumors, abscesses, and cysts.
Acceptance of the Current Diagnosis
The client’s current diagnosis is urinary tract infection (UTI), mainly characterized by fever, a persistent and strong urge to urinate, chills, burning sensation when urinating, foul-smelling and cloudy urine, and pelvic pain. The client reports dysuria, frequency, and urgency, which have persisted for the past year. These symptoms align with her current diagnosis, UTI; hence it should be accepted. Additionally, the UTI is characterized by objective data, including hematuria, fever/chills, oliguria, foul-smelling urine, suprapubic region, or abdominal pain. The client’s objective data indicates mild tenderness to palpation in the client’s suprapubic area. Therefore, the client’s current diagnosis should be accepted.
Overall, the client is a 32-year-old woman who presented to the clinic with dysuria, frequency, and urgency, which have persisted for the past year. Additional subjective data, including the client’s history of STDs or previous UTI incidents, information regarding using protection during sexual intercourse and experiencing pain or discomfort during intercourse, and details about any discharge or blood spots are needed to assist the healthcare provider in making an appropriate diagnosis for this client. The objective data indicates mild tenderness to palpation in the client’s suprapubic region, no adnexal tenderness, a normal-sized uterus and adnexa, no vaginal discharge, and a normal cervix. However, additional objective data, including the presence or absence of blood in the urine, color, smell of their urine, and details of chills/fever, are needed to assist in the client’s diagnosis. The client’s assessment is urinary tract infection (UTI), mainly characterized by fever, a persistent and strong urge to urinate, chills, burning sensation when urinating, foul-smelling and cloudy urine, and pelvic pain. These symptoms are reported in the client’s objective and subjective data. Therefore, her assessment is supported by subjective and objective data and should be accepted as the most appropriate diagnosis for this client.
References
Beahm, N. P., Nicolle, L. E., Bursey, A., Smyth, D. J., & Tsuyuki, R. T. (2017). The assessment and management of urinary tract infections in adults: guidelines for pharmacists. Canadian Pharmacists Journal/Revue des Pharmaciens du Canada, 150(5), 298-305. Doi: 10.1177/1715163517723036
Flores-Mireles, A., Hreha, T. N., & Hunstad, D. A. (2019). Pathophysiology, treatment, and prevention of catheter-associated urinary tract infection. Topics in spinal cord injury rehabilitation, 25(3), 228-240. DOI: 10.1310/sci2503-228.
Gupta, K., Grigoryan, L., & Trautner, B. (2017). Urinary tract infection. Annals of internal medicine, 167(7), 49-64. https://doi.org/10.7326/AITC201710030
Assessment of the genitalia and rectum is vital in depicting genitourinary and gastrointestinal abnormalities respectively. A rectal examination is necessary to complete an abdominal exam. Meanwhile, assessment of the genitalia is usually sensitive and must be done in the presence of a chaperone. In the subsequent paragraphs, potential history, physical exam, and differential diagnosis shall be explored based on a case scenario of T.S. a 32-year-old woman who presents with dysuria, frequency, and urgency for two days. She is sexually active and has had a new partner for the past three months.
Subjective
A triad of urgency, frequency, and dysuria characterizes a pathology that is most likely in the urinary tract. Consequently, it is essential to inquire about associated symptoms such as hematuria, fever, and malaise. Association with malaise and fever is common in urinary tract infections. Similarly, it is important to inquire about the presence of any abnormal vaginal discharge, and burning sensation during urination since she is sexually active and a sexually transmitted infection might be the cause of her symptoms. Likewise, changes in the smell and color of the urine must be elicited as well as associated suprapubic pain. Related to sexually transmitted infections, it is crucial to inquire about the number of sexual partners if similar symptoms have manifested in her partner or the use of protection during intercourse (Garcia & Wray, 2022).
Similarly, her last menstrual period must be known to determine if pregnant as this will impact the management (Bono et al., 2022). Additionally, a history of medication use, alcohol, smoking, and use of illicit drugs must be elicited. A history of contact with an individual with a chronic cough or TB prior to the occurrence of the previous symptoms must be elicited as urogenital TB may present similarly. Finally, it is crucial to inquire about any history of trauma or recent urethral catheterization as these are common risk factors for urinary tract infections.
Objective
The vital signs are mandatory in this patient as it is a pelvic exam. In the general exam, the mental and nutrition status of the patient must be noted. Additionally, a complete abdominal exam must be conducted as the patient has flank pain and suprapubic tenderness. Palpation of the abdomen for any masses and percussion of the flank for costovertebral angle tenderness must be done (Bono et al., 2022). Similarly, complete respiratory and cardiovascular exams must be conducted as a routine during the assessment of any patient. Finally, a digital rectal examination must be performed to exclude associated rectal abnormalities.
Assessment
In addition to urinalysis, STI, and pap smear testing, a complete blood count and urine culture must be conducted as the patient presents with signs of infection. Similarly, a pregnancy test must be conducted as this may complicate urinary tract infections. Additionally, she has no appetite and therefore a random blood sugar must be done to exclude hypoglycemia. Similarly, urea, creatinine, and electrolyte must be conducted to check the renal function as the patient has flank pain. Finally, Inflammatory markers such as ESR and CRP as well as blood cultures must be done as the patient has flank pain which may indicate pyelonephritis (Bono et al., 2022). Imaging tests are not necessary for the diagnosis of lower UTI. However, the patient has flank pain, and therefore, a CT scan of the abdomen and pelvis with or without IV contrast as well as an ultrasound of the kidneys and bladder must be done to identify any pathologies and outline the architecture of the kidney and bladder (Belyayeva & Jeong, 2022)
The possible diagnoses include a urinary tract infection and a sexually-transmitted infection. Urinary tract infections refer to the infection of the bladder, urethra, ureters, or kidneys (Bono et al., 2022). UTIs are more common in women, a consequence of a short urethra and proximity of the anal and genital regions (Bono et al., 2022). A triad of frequency, dysuria, and urgency collectively defines the irritative lower urinary tract symptoms (Bono et al., 2022). Similarly, suprapubic tenderness is a key feature of lower urinary tract infections. However, the patient is also feverish and has flank pain which also denotes the potential for involvement of the upper urinary tract (Bono et al., 2022). T.S is also sexually active, a risk factor for urinary tract infection.
A sexually transmitted infection is another possible diagnosis. T.S is sexually active and she has had her new partner for the last three months which is a key risk factor for this condition (Garcia & Wray, 2022). Most STIs present with suprapubic pain. Most STIs are asymptomatic and if symptomatic manifests with urethral discharge, vaginal discharge, pruritus, and pain (Garcia & Wray, 2022). T.S was negative for the aforementioned features.
Other differential diagnoses include pyelonephritis, interstitial cystitis, and urethritis due to an STI. Pyelonephritis is of the renal pelvis and parenchyma (Belyayeva & Jeong, 2022). It is usually a complication of ascending bacterial infection of the bladder and manifests principally with frequency, dysuria, urgency, fever, malaise, flank pain, and suprapubic pain (Belyayeva & Jeong, 2022). Interstitial cystitis is a chronic noninfectious idiopathic cystitis associated with recurrent suprapubic pain (Daniels et al., 2018). It presents with urgency, frequency, suprapubic discomfort, and pain relieved by voiding. T.S has some of these features although the gradual onset of symptomatology and a duration of more than six weeks is required for the diagnosis of this condition (Daniels et al., 2018). Finally, urethritis secondary to an STI may present in females with only frequency, urgency, and dysuria with minimal or no vaginal discharge (Young et al., 2022).
Conclusion
Assessment of the genitalia and rectum is sensitive and may help identify abnormalities of the rectum and genitourinary tract. Most abnormalities of the genitourinary system particularly UTIs and STIs can be diagnosed clinically. Consequently, a comprehensive history and physical examination are mandatory. Most UTIs are common in females. Pregnancy must always be excluded in a patient presenting with features suggestive of a UTI.
References
Belyayeva, M., & Jeong, J. M. (2022). Acute Pyelonephritis. https://pubmed.ncbi.nlm.nih.gov/30137822/
Bono, M. J., Leslie, S. W., & Reygaert, W. C. (2022). Urinary Tract Infection. https://pubmed.ncbi.nlm.nih.gov/29261874/
Daniels, A. M., Schulte, A. R., & Herndon, C. M. (2018). Interstitial cystitis: An update on the disease process and treatment. Journal of Pain & Palliative Care Pharmacotherapy, 32(1), 49–58. https://doi.org/10.1080/15360288.2018.1476433
Garcia, M. R., & Wray, A. A. (2022). Sexually Transmitted Infections. https://pubmed.ncbi.nlm.nih.gov/32809643/
Young, A., Toncar, A., & Wray, A. A. (2022). Urethritis. https://pubmed.ncbi.nlm.nih.gov/30725967/