NURS 6512 Assignment Assessing The Genitalia And Rectum
Walden University NURS 6512 Assignment Assessing The Genitalia And Rectum-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University NURS 6512 Assignment Assessing The Genitalia And Rectum assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.
How to Research and Prepare for NURS 6512 Assignment Assessing The Genitalia And Rectum
Whether one passes or fails an academic assignment such as the Walden University NURS 6512 Assignment Assessing The Genitalia And Rectum depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.
After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.
How to Write the Introduction for NURS 6512 Assignment Assessing The Genitalia And Rectum
The introduction for the Walden University NURS 6512 Assignment Assessing The Genitalia And Rectum is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.
How to Write the Body for NURS 6512 Assignment Assessing The Genitalia And Rectum
After the introduction, move into the main part of the NURS 6512 Assignment Assessing The Genitalia And Rectum assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.
Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.
How to Write the Conclusion for NURS 6512 Assignment Assessing The Genitalia And Rectum
After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.
How to Format the References List for NURS 6512 Assignment Assessing The Genitalia And Rectum
The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.
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Sample Answer for 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
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Sample Answer 2 for NURS 6512 Assignment Assessing The Genitalia And Rectum
Genitourinary problems are among the public health concerns globally. Nurses and other healthcare providers adopt evidence-based interventions that would optimize patient outcomes in the treatment of these conditions. Subjective and objective data help nurses to formulate diagnoses and treatment plans. Therefore, this essay examines TS’s case study. TS has presented to the hospital complaining of dysuria, urgency, and frequency for the last two days. The essay focuses on topics that include additional subjective and objective information that should be obtained from the patient, if subjective and objective data supports the assessment, appropriate diagnostics, accepting or rejecting the diagnosis, and differential diagnoses to be considered for the patient.
Additional Subjective Information
Additional subjective information should be obtained from TS. Firstly, information about the character of her urine should be obtained. This includes information such as the smell and color of the urine. Bloodstained urine could indicate bladder problems while urine with a strong smell could imply that TS has a urinary tract infection. The nurse should also ask for information about the presence or absence of abnormal vaginal discharge. For instance, yellow or purulent vaginal discharge would indicate sexually transmitted infections. The character of TS’s symptoms should also be obtained. This includes seeking information on the factors that precipitate or alleviate her urinary symptoms. She should be asked about any activity that worsens or relieves her symptoms (Kaur & Kaur, 2021). The nurse should also assess her current level of pain using the pain rating scale. Pain rating could indicate the severity of her condition.
The nurse should also ask TS about her sexual habits. This includes sexual preferences and the use of protection when engaging in sexual intercourse. The information would help the nurse rule out causes such as sexually transmitted infections. Additional sexual-related information that should be obtained includes the use of contraceptives, the last menstrual period, and menstrual cycle problems. The nurse should also obtain information about any history of recurrent urinary tract infections. This would help determine if she has chronic urinary tract infections. Similarly, information about the history of sexually transmitted infections should be obtained to rule them out in her case. Information about her partner’s history of sexually transmitted infections and testing should also be obtained to rule out a risk of STD transmission. Information about TS’s social history is also needed. This includes data about smoking, dietary practices, and alcohol use (Bono et al., 2024). The nurse should also rule out the potential of heredity of TS’s problem. Information about a family history of health problems such as kidney disease or symptoms that TS has should be obtained.
Additional Objective Information
Additional objective information should be obtained in TS’s case to guide the development of an accurate diagnosis and treatment plan. Firstly, the nurse should provide information about TS’s general appearance. Information such as her overall grooming, weight changes, presence or absence of chills or fatigue should be included in the objective portion. Abdominal assessment should provide information about the presence or absence of organomegaly, or abnormal pulsations. The case study should also provide detailed information about urine description (Bono et al., 2024). This includes urine color, smell, and the presence or absence of pus or blood in the urine.
The nurse should also provide information about the assessment of the genitourinary system. Information such as the presence or absence of vaginal discharge, lesions, or trauma should be documented to rule out causes such as sexually transmitted infections and intimate partner violence. The nurse should also assess TS’s level of pain. She should use a pain rating scale to determine the severity of her pain and prioritize the treatment plan accordingly (Boon et al., 2021). Pain assessment should also include TS’s experiences of pain on abdominal palpation.
If the Assessment is Supported by Subjective and Objective Information
Subjective and objective information support TS’s assessment. Nurses obtain subjective information by asking patients questions that relate to their health problems and different body systems. The subjective data helps the nurse determine the severity of a health problem and its impact on the client’s health and overall well-being. TS’s case study has subjective information. They include her chief complaints, history of her presenting illness, surgical history, past medical history, medication use, allergies, and social history. Nurses obtain objective data from their patients by using methods such as inspection, palpation, auscultation, and percussion. The objective data validates subjective claims by the patient. The case study has objective information. They include TS’s vital signs, abdominal assessment, and diagnostics ordered.
Appropriate Diagnostics for the Case
Some diagnostic and laboratory investigations should be ordered in TS’s case study to guide develop an accurate diagnosis and treatment plan. Firstly, a urinalysis test should be performed to rule out urinary tract infections. A diagnosis of urinary tract infection will be made should her urine test reveal the presence of leucocytes and nitrites. The presence of proteins in urine will indicate cardiovascular problems such as hypertension while the presence of glucose would imply that TS has diabetes. The presence of ketones will indicate the possibility of dehydration. TS should also be tested for sexually transmitted infections. Blood tests, vaginal swabs, and urine samples should be taken to rule out sexually transmitted infections such as gonorrhea and chlamydia infections. An abdominal CT scan should also be performed to rule out causes such as kidney stones. MRI might also be needed to rule out kidney stones and other renal pathologies that could be associated with TS’s problems (Kaur & Kaur, 2021). Lastly, cervical screening for cervical cancer should be done. Cervical screening would also help rule out other causes such as vaginosis in TS’s case.
Accepting or Rejecting Current Diagnosis Differential Diagnoses
I would accept the current diagnosis. TS’s complaints align with those seen in patients with urinary tract infections and sexually transmitted infections. Often, patients with these conditions experience dysuria, urgency, frequency, and fever, which are present in TS’s case (Bono et al., 2024). Therefore, additional diagnostic and laboratory tests will help determine if TS is suffering from STDs or UTIs. TS’s history of engaging in unprotected sex with her new partner makes STDs among the probable diagnoses to be considered.
One of the differential diagnoses that should be considered for TS is perinephric abscess. Perinephric access is a condition that develops from the spread of infections from other regions of the genitourinary tract to the kidneys (Okafor & Onyeaso, 2024). The infections result in the development of abscesses. Patients experience symptoms that include fever, chills, nausea, vomiting, flank pain, and fatigue (Adams et al., 2020). Unlike urinary tract infections or STDs, patients with perinephric abscesses might not experience symptoms such as urinary frequency or dysuria.
The other differential diagnosis that should be considered for TS is urethral syndrome. Urethral syndrome is a genitourinary condition characterized by urinary frequency, urgency, suprapubic pain, and dysuria. It develops from any condition that causes urethral irritation and inflammation. The urethral syndrome can develop due to sexually transmitted infections, urinary tract infections, or the use of foods that irritate the urethra (Sell et al., 2021). A confirmed diagnosis of either UTI or STD might indicate its co-existence with urethral syndrome.
The last differential diagnosis that should be considered for TS is kidney stones. Kidney stones develop from crystal deposition in the kidneys. Factors such as dehydration, intake of diets rich in salt, and overweight or obesity predispose individuals to kidney stones. Patients experience symptoms such as severe, sharp back or flank pain, pain radiating to the groin or lower abdominal regions, and dysuria. Patients might also report passing red or brown urine, foul-smelling and cloudy urine, frequency, nausea and vomiting, chills, and fever (Thongprayoon et al., 2020; Wang et al., 2021). The absence of red or brown-colored urine and sharp pain show that kidney stones are not the cause of TS’s complaints.
Conclusion
Overall, additional subjective and objective information should be obtained in the case study. Subjective and objective data support the assessment. Additional diagnostics and laboratory investigations should be ordered to develop an accurate diagnosis and treatment plan. I accept the current diagnosis based on TS’s symptoms. The three differential diagnoses that should be considered in TS’s case study include kidney stones, urethral syndrome, and perinephric abscess.
References
Adams, M., Bouzigard, R., Al-Obaidi, M., & Zangeneh, T. T. (2020). Perinephric abscess in a renal transplant recipient due to Mycoplasma hominis: Case report and review of the literature. Transplant Infectious Disease, 22(5), e13308. https://doi.org/10.1111/tid.13308
Bono, M. J., Leslie, S. W., & Reygaert, W. C. (2024). Uncomplicated Urinary Tract Infections. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK470195/
Boon, H. A., Bruel, A. V. den, Struyf, T., Gillemot, A., Bullens, D., & Verbakel, J. Y. (2021). Clinical Features for the Diagnosis of Pediatric Urinary Tract Infections: Systematic Review and Meta-Analysis. The Annals of Family Medicine, 19(5), 437–446. https://doi.org/10.1370/afm.2684
Kaur, R., & Kaur, R. (2021). Symptoms, risk factors, diagnosis and treatment of urinary tract infections. Postgraduate Medical Journal, 97(1154), 803–812. https://doi.org/10.1136/postgradmedj-2020-139090
Okafor, C. N., & Onyeaso, E. E. (2024). Perinephric Abscess. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK536936/
Sell, J., Nasir, M., & Courchesne, C. (2021). Urethritis: Rapid Evidence Review. American Family Physician, 103(9), 553–558.
Thongprayoon, C., Krambeck, A. E., & Rule, A. D. (2020). Determining the true burden of kidney stone disease. Nature Reviews Nephrology, 16(12), Article 12. https://doi.org/10.1038/s41581-020-0320-7
Wang, Z., Zhang, Y., Zhang, J., Deng, Q., & Liang, H. (2021). Recent advances on the mechanisms of kidney stone formation (Review). International Journal of Molecular Medicine, 48(2), 1–10. https://doi.org/10.3892/ijmm.2021.4982
Sample Answer 3 for NURS 6512 Assignment Assessing The Genitalia And Rectum
The SOAP note concerns T.S, a 32-year-old female with symptoms of pain when voiding, urinary frequency, and urgency that has lasted two days. She mentions that she had similar symptoms years back. She also reports having flank pain that disrupts her sleep, and she feels warm. Physical exam findings include mild suprapubic tenderness. The purpose of this paper is to analyze the SOAP note, identify additional information needed, and describe likely diagnoses.
Subjective Portion
The HPI in the subjective portion should include information describing the timing of the dysuria. This includes whether the dysuria occurs at the start or end of voiding to establish the underlying pathology. Dysuria at the start suggests urethral pathology, while at the end of voiding suggests bladder pathology (AlShuhayb et al., 2022). The HPI should also include the persistence and severity of the dysuria. In addition, information on the characteristics of urine should be provided, for instance, the amount of urine and if the urine is malodorous, cloudy, or bloody. Information on the patient’s contraceptive use should be included in the HPI. The subjective portion should also include the client’s immunization history, current medications, reproductive history, including menstrual history, family history, and social history. Furthermore, the review of systems should have included each body system and indicated pertinent positives and negatives.
Objective Portion
The objective portion only contains findings from vital signs and pelvic exam. It should include anthropometric measures, height, weight, and BMI, vital in determining the client’s general nutritional status. In addition, physical findings from general, cardiovascular, and respiratory exams should be included since they are vital body systems. Findings from the examination of the external genitalia should be included to identify if the patient has vulvar ulcers, vesicles, pustules, mucosal inflammation, or vaginal discharge (AlShuhayb et al., 2022).
Assessment Supported
The identified assessment findings are UTI and STI. The subjective findings of dysuria, urinary frequency, urgency, and flank pain support UTI. It is also supported by objective findings of suprapubic tenderness (Czajkowski et al., 2021). STI is supported by the findings of dysuria, flank pain, feeling warm, and suprapubic tenderness.
Diagnostic Tests
Appropriate diagnostic tests include dipstick urinalysis, urine culture, blood culture, and vaginal nucleic acid amplification test (NAAT). Urinalysis is the most helpful diagnostic test in a patient with dysuria. Urine culture is indicated for patients with risk factors for complicated UTI or those who do not respond to initial therapy (Tai et al., 2022). A blood culture will be indicated since the patient reports feeling warm to, rule out systemic infection. In addition, vaginal NAAT will identify the presence of Chlamydia trachomatis and Neisseria gonorrhoeae.
Rejection or Acceptance
UTI is consistent with the patient’s pain symptoms when voiding, increased frequency, urgency, flank pain, and suprapubic tenderness. Thus, I would accept UTI as a diagnosis. STI is a broad term for other STIs; the diagnosis should be specific. Besides, the patient does not have sufficient physical findings to support STI; thus, I would reject the diagnosis.
Possible Conditions
Urinary Tract Infection (UTI): UTI in females present with symptoms like dysuria, a sensation of a full bladder, urinary urgency, frequency, suprapubic tenderness, flank pain, and blood in the urine (Jelly et al., 2022). It is also characterized by systemic symptoms such as fevers, chills, and malaise. The patient’s dysuria, increased frequency, urgency, flank pain, feeling warm, and mild suprapubic tenderness makes UTI a possible diagnosis.
Cystitis: This is a bladder infection. The onset of symptoms is usually sudden. Typical manifestations include dysuria, urinary frequency, urgency, and passing small volumes of urine (Frazier & Huppmann, 2020). Other common symptoms are suprapubic pain, low back pain, and nocturia. The patient has dysuria, increased frequency, urgency, and suprapubic tenderness, making Cystitis a possible diagnosis.
Ureth
ritis: This is inflammation of the urethra. Clinical features include urethral discharge dysuria, urethral irritation, or itch (Sadoghi et al., 2022). This is a differential diagnosis owing to the patient’s history of dysuria.
Conclusion
The subjective portion should have additional information to describe the dysuria and characteristics of urine. The ROS should have included pertinent negatives and positives from other systems. The objective portion lacks the anthropometric measurements and findings from general, cardiovascular, respiratory, and external genitalia exams. UTI is an acceptable diagnosis, but STI should be rejected due to a lack of adequate physical findings to support it. The possible diagnoses are UTI, cystitis, and urethritis.
References
AlShuhayb, F. H., Alanazi, M. G., Alghizzi, A. A., Khinkar, H. J., Ali, F. N., Alnahari, E. H. H. O., … & Aleidi, H. A. (2022). An Overview on Urinary tract infection Diagnostic and Management Approach in Primary Health Care. Archives of Pharmacy Practice, 1, 15. https://doi.org/10.51847/3neIMfJIpm
Czajkowski, K., Broś-Konopielko, M., & Teliga-Czajkowska, J. (2021). Urinary tract infection in women. Przeglad menopauzalny = Menopause review, 20(1), 40–47. https://doi.org/10.5114/pm.2021.105382
Frazier, R. L., & Huppmann, A. R. (2020). Educational Case: Acute Cystitis. Academic pathology, 7, 2374289520951923. https://doi.org/10.1177/2374289520951923
Jelly, P., Verma, R., Kumawat, R., Choudhary, S., Chadha, L., & Sharma, R. (2022). Occurrence of urinary tract infection and preventive strategies practiced by female students at a tertiary care teaching institution. Journal of Education and health promotion, pp. 11, 122. https://doi.org/10.4103/jehp.jehp_750_21
Sadoghi, B., Kränke, B., Komericki, P., & Hutterer, G. (2022). Sexually transmitted pathogens causing urethritis: A mini-review and proposal of a clinically based diagnostic and therapeutic algorithm. Frontiers in medicine, 9, 931765. https://doi.org/10.3389/fmed.2022.931765
Tai, L. H., Ho, S. W., Yeh, C. B., & Chen, C. C. (2022). Woman With Dysuria. Annals of Emergency Medicine, 79(5), e103-e104. https://doi.org/10.1016/j.annemergmed.2021.11.012
Sample Answer 4 for NURS 6512 Assignment Assessing The Genitalia And Rectum
Health assessment helps clinicians develop the most effective care plan from clinical reasoning, diagnosis, and treatment of the patient effective, based on the provided information. For instance, when carrying out a genitourinary assessment of a patient, it is very important to base the investigations on the patient’s subjective data and diagnostic examination (Chen & Zeng, 2020). The provided case study for this assignment presents a 32-year-old female patient with a chief complaint of frequency, dysuria, and urgency for the past two days. A thorough health assessment is required for further understanding of the condition the patient is suffering from to promote the development of an appropriate care plan. Hence, this paper aims at exploring additional subjective and objective information necessary to promote the diagnosis process of this patient.
Additional Subjective Information
The subjective information provided by the patient includes the chief complaint of increased urine frequency, urgency, and painful urination. Following the acronym “OLD CARTS” for further elaboration of the patient’s chief complaint, only the onset, and location of the symptoms have been provided since the patient reports having the above symptoms for the past two days (Kim et al., 2019). However, additional information regarding the patient presenting symptoms such as severity, alleviating, and aggravating factors are also crucial in promoting further understanding of the patient’s condition.
Under current patient medication, the patient reports not taking any medication at the moment for the present condition or any other medical condition. However, information regarding the patient’s allergies and past medical history are missing (Chen & Zeng, 2020). The patient also reports a history of tonsillectomy in 2001, and appendectomy in 2020, which are essential aspects of the patient’s subjective information. The immunization status of the patient is however missing, which is crucial in understanding the cause of the patient’s condition and how it should be managed.
The patient’s social and family history are also missing, which are crucial in determining the risk factors which predispose the patient to certain medical conditions. Additionally, the patient’s reproductive history is also missing, such as the menstrual cycle is also missing, in addition to health maintenance such as eating habits and sleeping patterns (Paladine & Desai, 2018). Finally, the review of systems for this patient is also missing. This information is crucial for further understanding the normal functioning of different body systems, to determine which systems have been affected by the patient’s condition.
Additional Objective Information
The objective information is usually collected upon conducting a physical examination of the patient while focusing only on pertinent data to the reported patient’s chief complaint. The clinician needs to start by evaluating the patient’s general health by describing their general appearance such as alert, fatigued, or well-groomed (Kim et al., 2019). The patient’s vitals dada has been provided, but still lacks information on the patient’s height and weight which is needed in calculating her BMI and determining if she has an ideal body weight, obese, overweight, or underweight. Cardiovascular and respiratory examination findings are also necessary for determining the functioning of the two systems, of which abnormalities are associated with poor health and increased risk of infections.
Additionally, since the patient presents with symptoms of a genitourinary disease, it is quite crucial to conduct a comprehensive examination of the genitourinary system. Mild tenderness of the suprapubic area was reported, in addition to the absence of vaginal discharge and adnexal tenderness. Upon conducting the pelvic bimanual examination, it was noted that the patient had normal-sized adnexa and uterus with a normal cervix in appearance. In addition to this information, the characteristic of the patient’s urine, in terms of appearance and odor should have also been provided for further understanding of the condition the patient is suffering from (Charvériat & Fritel, 2019). The reported objective information is necessary in guiding the type of diagnostic tests to order to promote an accurate diagnosis of the patient.
Assessment
The provided subjective and objective information relatively supports the assessment of the patient which suggests the presence of urinary tract infection (UTI). The patient is positive for UTI symptoms such as increased frequency and urgency and pain during urination as demonstrated in the subjective portion of the patient’s history. Additional UTI symptoms include foul-smelling and cloudy urine among others (Paladine & Desai, 2018). The objective portion of the patient history on the other hand reveals mild tenderness in the suprapubic region which might have resulted from urine retention confirming the presence of an infection. However, urinalysis and urine culture are required to confirm this assessment.
Diagnostics Appropriateness
Given that most genitourinary diseases she common symptoms such as increased urgency and frequency, certain diagnostic tests are needed for the clinician to be able to come up with an accurate diagnosis. Such tests include urinalysis, to assess for the presence of a bacteria, virus, or any other causative microorganism (Kim et al., 2019). A urine culture is needed to determine the type of bacteria causing the infection. Consequently, a cystoscopy test is also necessary to examine infections of the urethra and bladder and determine the cause of the urinary tract infection.
Differential Diagnosis
Based on the provided information, I would accept the current UTI diagnosis, which is supported by symptoms such as increased urine frequency, dysuria, and urgency for two days. Physical examination findings such as mild tenderness in the suprapubic region also confirm the presence of an infection. However, I would order urinalysis and urine culture to identify the actual causative microorganisms and confirm the primary diagnosis ad rule out the differential diagnosis (Johnson & Russo, 2018). Some of the differential diagnoses include vaginitis, pyelonephritis, and pelvic inflammatory disease (PID).
Vaginitis is an inflammatory condition of the vagina characterized by pain, itchiness, and discharge. It is usually caused by an infection or change in the balance of the vaginal normal flora. The patient is positive for pain during urination (Paladine & Desai, 2018). However, according to the Amsel criteria, the diagnosis of vaginitis requires the presence of clue cells on microscopy of vaginal fluid, vaginal pH higher than 4.5, milky discharge, and a positive whiff test.
Pyelonephritis or kidney infection is a type of UTI which normally starts in the patient’s bladder or urethra and travels to both or one of the patient’s kidneys (Johnson & Russo, 2018). Patients with this disease normally present with frequent urination, and pain during urination, just like the patient in the provided case study in addition to other symptoms such as fever, fatigue and nausea, and vomiting. Urinalysis or culture is required to confirm this diagnosis, in addition to the patient presenting symptoms as demonstrated above.
Finally, PID is an infection that normally affects the female reproductive organs. It usually occurs when sexually transmitted bacteria travel from the patient’s vagina to the uterus, fallopian tube, or even ovaries (Charvériat & Fritel, 2019). The patient in the provided case study is sexually active and recently changes a sex partner which puts her at risk of this infection. Patients diagnosed with this disease normally present with symptoms such as painful urination, pain during sex, nausea, vomiting, fever, chills, irregular menstrual periods, and abnormal vaginal discharge. To confirm the diagnosis of PID, an endometrial biopsy with histopathologic evidence suggesting endometritis is required. Transvaginal sonography and magnetic resonance imaging of the patient’s pelvic area may also be required to confirm this diagnosis.
Conclusion
The female patient in the provided case study presents to the clinic complaining of increased frequency, pain with urination, and urgency. Associated symptoms include lack of appetite, flank pain, and pelvic discomfort. These symptoms suggest a UTI diagnosis, however, additional subjective and objective information is required to confirm this diagnosis. Several diagnostic tests also needed to be ordered to rule out the differentials and come up with the primary diagnosis. Such tests include cystoscopy tests, urine tests, and urine culture. The possible differential diagnosis includes vaginitis, Pyelonephritis, and PID.
References
Charvériat, A., & Fritel, X. (2019). Diagnosis of pelvic inflammatory disease: clinical, paraclinical, imaging, and laparoscopy criteria. CNGOF and SPILF pelvic inflammatory diseases guidelines. Gynecologie, Obstetrique, Fertilite & Senologie, 47(5), 404-408. DOI: 10.1016/j.gofs.2019.03.010
Chen, J., & Zeng, R. (2020). Frequency, Urgency, and Dysuria. In Handbook of Clinical Diagnostics (pp. 75-76). Springer, Singapore.
Johnson, J. R., & Russo, T. A. (2018). Acute pyelonephritis in adults. New England Journal of Medicine, 378(1), 48-59. https://doi.org/10.1056/nejmx180009
Kim, W. B., Lee, S. W., Lee, K. W., Kim, J. M., Kim, Y. H., & Kim, M. E. (2019). How Women Evaluate Syndromic Recurrent Urinary Tract Infections. Urogenital Tract Infection, 14(2), 46-54. https://doi.org/10.14777/uti.2019.14.2.46
Paladine, H. L., & Desai, U. A. (2018). Vaginitis: diagnosis and treatment. American family physician, 97(5), 321-329. PMID: 29671516