Assessing the Genitalia and Rectum Essay
Assessing the Genitalia and Rectum Essay
Subjective Data
Chief complaint: “I have bumps on my bottom that I want to have checked out.”
History of presenting illness: AB is a 21years old college student presenting with external bumps on her genital area. The bump is there for an unspecified duration of time, is painless, and feels rough. Her initial sexual encounter was at the age of 18years and has had multiple partners. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed. She denies purulent vaginal discharge and skin itchiness around the genitalia. Assessing the Genitalia and Rectum Essay
Current Medications: Symbicort 160/4.5mcg
Allergies: she has no known food and drug allergies
Past medical and surgical history: she has asthma and is on treatment. She had a sexually transmitted infection (chlamydia) two years ago.
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Social history: she is married and has three children. She denies tobacco use and occasionally takes alcohol.
Family history: she has a positive history of hypertension from her father and mother. Her mother has GERD. She denies a family history of breast cancer.
Review of systems
General: she denies weight loss, fever, chills, weakness, or fatigue.
HEENT: the patient denies eye pain, blurring of vision, nasal congestion, running nose, sore throat, ear pain, headache, and dizziness.
Skin: the patient has no acne, rash, scaling, and itching skin.
Cardiovascular: she denies orthopnea, paroxysmal nocturnal dyspnea, chest pain, palpitations, syncope, and edema.
Respiratory: she denies chest pain, wheezing, tachypnea, shortness of breath, cough, or sputum.
Gastrointestinal: she denies loss of appetite, anorexia, nausea, vomiting, diarrhea, and abdominal pain.
Genitourinary: she denies dysuria, urgency, and hematuria.
Neurological: she denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities.
Musculoskeletal: she denies muscle, back pain, joint pain, or stiffness. Assessing the Genitalia and Rectum Essay
Hematologic: she denies anemia, bleeding, or bruising.
Lymphatic: she has enlarged non-tender inguinal lymph nodes.
Psychiatric: she denies change of mood, hallucinations, deliriums, or anxiety.
Endocrinology: she denies sweating and heat intolerance.
Objective Data
General examination: the patient is alert and oriented. She has inguinal lymphadenopathy. She has no pallor, jaundice, cyanosis and edema, dehydration, and finger clubbing.
Vitals: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs
Genital: the patient has a normal female hair pattern distribution. There is no mass or swelling. The urethral meatus is intact without erythema or discharge and the perineum is intact. The vaginal mucosa is pink and moist with rugae present. The patient has a firm, round, small, painless ulcer noted on the external labia.
Heart: the heart sounds are present in S1 and S2, the pulse has a regular rate and rhythm, and there are no murmurs.
Lungs: CTA, chest wall symmetrical
Abdominal examination: the abdomen is soft. There are normoactive bowel sounds. There is no rebound, murphy’s signs, and McBurney.
Assessment
The patient has a painless bump on her bottoms. She is sexually active with multiple partners and had a sexually transmitted infection two years ago. She has a round, small, firm, and painless ulcer at the external labia. I would ask the patient about the number of sexual partners and if she engages in anal and oral sex. Unprotected anal sexual intercourse with multiple partners increases the risk of human papillomavirus and cervical cancer. I will ask if she has a bad vaginal odor, dyspareunia, and post-coital bleeding. I would ask about her social-economic status and occupation because poverty increases the risk of promiscuity hence, sexually transmitted infections.
In the objective portion, I will examine the oral cavity to check for ulcers and candidiasis. Patients with HIV and other sexually transmitted diseases have oral sores and oral thrush. I would examine the anal region to check for fissures and hemorrhoids. These are common in patients engaging in anal sex. The subjective and objective data support the proposed diagnosis. The chancre is a predominant lesion for primary syphilis that occurs four weeks after infection. It is oval, indurated, slightly elevated, painless, and crusty. It is associated with regional non-tender lymph nodes. The appropriate diagnostic tests for this patient are serological screening for VDRL, CSF VDRL, Pap smear, and complete blood count with differential and platelet count.
Differential diagnosis
- Primary syphilis
- Genital warts
- Bowenoid papulosis
Syphilis is a viral infection caused by the spirochete treponema pallidum. Its mode of transmission is through sexual contact with infectious lesions. The patient presents with painless chancre at the site of contact (Forrestel, et al, 2020). This is the patient’s actual diagnosis because she presents with a firm, round, small, painless ulcer noted on the external labia. She has a previous history of sexually transmitted infections and has multiple partners.
Genital warts are the result of Human papillomavirus producing epithelial tumors of the skin and the mucous membranes. It is more prevalent in women aged between 17-33 years old. Clinical signs and symptoms are painless bumps, discharge, and pruritus (Grennan, D. 2019). Risk factors are previous or recurrent sexually transmitted infections. However, this is not the patient’s actual diagnosis because she denies discharge and pruritus.
Bowenoid papulosis is focal epidermal hyperplasia of the external genitalia. It presents with single or multiple painless papules (Chamli & Zaouak, 2020). These papules may be of normal skin color or have a red, brown, or fresh-colored pigmentation. This Bowenoid papulosis is common in people who engage in oral sexual activity. Assessing the Genitalia and Rectum Essay
Content
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| With regard to the SOAP note case study provided and 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. |
Points Range: 10 (10%) – 12 (12%)
The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation.
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Points Range: 7 (7%) – 9 (9%)
The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.
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Points Range: 4 (4%) – 6 (6%)
The response vaguely analyzes the subjective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.
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Points Range: 0 (0%) – 3 (3%)
The response inaccurately analyzes the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
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| · Analyze the objective portion of the note. List additional information that should be included in the documentation. |
Points Range: 10 (10%) – 12 (12%)
The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation.
Feedback: Assessing the Genitalia and Rectum Essay
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Points Range: 7 (7%) – 9 (9%)
The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation.
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Points Range: 4 (4%) – 6 (6%)
The response vaguely analyzes the objective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.
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Points Range: 0 (0%) – 3 (3%)
The response inaccurately analyzes the objective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
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| · Is the assessment supported by the subjective and objective information? Why or why not? |
Points Range: 14 (14%) – 16 (16%)
The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.
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Points Range: 11 (11%) – 13 (13%)
The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a clear explanation.
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Points Range: 8 (8%) – 10 (10%)
The response vaguely identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation.
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Points Range: 0 (0%) – 7 (7%)
The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.
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| · What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis? |
Points Range: 18 (18%) – 20 (20%)
The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis.
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Points Range: 15 (15%) – 17 (17%)
The response accurately describes appropriate diagnostic tests for the case and explains how the test results would be used to make a diagnosis.
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Points Range: 12 (12%) – 14 (14%)
The response vaguely and/or with some inaccuracy describes appropriate diagnostic tests for the case and vaguely and/or with some inaccuracy explains how the test results would be used to make a diagnosis.
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Points Range: 0 (0%) – 11 (11%)
The response inaccurately describes appropriate diagnostic tests for the case, with an inaccurate or missing explanation of how the test results would be used to make a diagnosis.
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| · Would you reject or accept the current diagnosis? Why or why not? · Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature. |
Points Range: 23 (23%) – 25 (25%)
The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature.
Feedback:
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Points Range: 20 (20%) – 22 (22%)
The response states whether to accept or reject the current diagnosis, with an accurate explanation of sound reasoning. The response accurately identifies three conditions as a differential diagnosis, with reasoning that is explained using three different references from current evidence-based literature.
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Points Range: 17 (17%) – 19 (19%)
The response states whether to accept or reject the current diagnosis, with a vague explanation of the reasoning. The response identifies two to three conditions as a differential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three or fewer references from current evidence-based literature.
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Points Range: 0 (0%) – 16 (16%)
The response inaccurately states or is missing a statement of whether to accept or reject the current diagnosis, with an explanation that is inaccurate and/or missing. The response identifies three or fewer conditions as a differential diagnosis, with reasoning that is missing or explained inaccurately using two or fewer references from current evidence-based literature.
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| Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
Points Range: 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
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Points Range: 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
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Points Range: 3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.
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Points Range: 0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
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| Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation |
Points Range: 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
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Points Range: 4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
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Points Range: 3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.
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Points Range: 0 (0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
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| Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. |
Points Range: 5 (5%) – 5 (5%)
Uses correct APA format with no errors.
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Points Range: 4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors.
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Points Range: 3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors.
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Points Range: 0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors.
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HI, PLEASE READ INSTRUCTION CAREFULLY. DO NOT USE OTHER STUDENT PAPER PLEASE BECAUSE I HAVE NO TIME FOR REVISION. THANK YOU
Assignment: Lab Assignment: Assessing the Genitalia and Rectum
The Lab Assignment Assessing the Genitalia and Rectum Essay
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.
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.
•
GENITALIA ASSESSMENT
Subjective:
• CC: “I have bumps on my bottom that I want to have checked out.”
• HPI: AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner during the past year. Her initial sexual contact occurred at age 18. She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.
• PMH: Asthma
• Medications: Symbicort 160/4.5mcg
• Allergies: NKDA
• FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD
• Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
• VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs
• Heart: RRR, no murmurs
• Lungs: CTA, chest wall symmetrical
• Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia
• Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, negMcBurney
• Diagnostics: HSV specimen obtained
Assessment:
• Chancre
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
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HERE ARE SOME INFORMATION/LINKS YOU CAN USE THEM.
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. Assessing the Genitalia and Rectum Essay
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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. Assessing the Genitalia and Rectum Essay
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)
Mealey, K., Braverman, P. K., & Koenigs, L. M. (2019). Why a pelvic exam is needed to diagnose cervicitis and pelvic inflammatory disease. Annals of Emergency Medicine, 73(4), 424–425. https://doi.org/10.1016/j.annemergmed.2018.11.028
Sanchez, C., Israel, R., Hughes, C., & Gorman, N. (2019). Well-woman examinations: Beyond cervical cancer screening. The Journal for Nurse Practitioners, 15(2), 189–194.e2. https://doi.org/10.1016/j.nurpra.2018.09.005
Centers for Disease Control and Prevention. (2021, April 13). Sexually transmitted disease surveillance, 2019. https://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. Assessing the Genitalia and Rectum Essay
