Assessing the Genitalia Essay Paper

Assessing the Genitalia Essay Paper

Case Overview

RG is a 30years old female patient at the ER presenting with dysuria and increased urinary frequency for three days. The pain was worse during urination. She used Tylenol with no relief. She reports flank pain, intermittent fever, and chills. She had UTI three years ago and a hysterectomy five years ago. Her father has hypertension and her mother has breast cancer. She is single, works as a bartender with a positive history of ETOH, and denies tobacco. She is allergic to PCN and sulfa. On examination, she has a fever, CVA tenderness, and lower abdominal pain on palpation. A urine specimen was collected for STD screening. The differential diagnoses are UTI and STI Assessing the Genitalia Essay Paper.

Subjective Portion

Subjective data includes patient particulars, chief complaint, HPC, PMH, current medication, allergies, surgical history, social history, family history, and review of systems. In this scenario, I would ask more about the patient’s reproductive health and sexual behavior. The patient’s LMP is not applicable and has a history of hysterectomy five years ago. I would ask if she had a pelvic inflammatory disease, prolapse of the uterus, or heavy menstrual periods that would result in a hysterectomy. Sexual behaviors increase the risk of sexually transmitted diseases and urinary tract infections, especially when there are many partners involved or it is not protected. Assessing the Genitalia Essay Paper

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Objective Data

The objective portion entails general examination, vitals, and systemic examination. The positive findings are fever, CVA tenderness, and pain in the lower abdomen upon palpation. I would check the genitalia for vaginal discharge and bruises. I would check the oral cavity for sores and oral candidiasis. These would help in establishing a sexually transmitted infection.

Does The Subjective And Objective Information Support The Assessment?

The subjective and objective data support the assessment because the patient has polyuria, dysuria, chills and rigors, flank pain, and a positive history of UTI three years ago. Upon examination, she has a fever, pain on palpation of both lower quadrants, and CVA tenderness. The subjective and objective information rules out STDs because there are no findings of classical signs of STDs.

Would Diagnostics Be Appropriate For This Case, And How Do The Results Make A Diagnosis?

The diagnostic test done is a urine sample for microscopy. It is appropriate for this patient because of the complaints suggestive of UTI. The urine sample checks for leukocytes, nitrites, proteins, ketones, pus cells, and epithelial cells. Leukocytes and nitrites are specific for urinary tract infections. Pelvic ultrasound, high vaginal swab for microscopy, and complete blood count would also confirm the diagnosis.

Would You Reject/Accept The Current Diagnosis?

Urinary tract infection has polyuria, dysuria, fever, chills, rigors, flank pain, and tenderness. The patient presents with similar symptoms and has a history of a UTI from three years ago. Hence, UTI is the primary diagnosis. Sexually transmitted infection is another probable differential for UTI because of the flank pain, chills, and rigors. She patient has a risky social behavior of ETOH that increases the chance of engaging in risky sexual behavior. It is excluded as the primary diagnosis because there is no information about the patient’s sexual behavior and its symptoms.

Differential Diagnosis

• Urinary tract infection
• Pyelonephritis
• Cystitis
• Vaginitis
• Pelvic inflammation disease

Urinary tract infection is the colonization of the urinary system by a microorganism such as fungi, bacteria, viruses, or parasites. The most common microorganism causing urinary tract infection is Escherichia-coli. Signs and symptoms of UTI are dysuria, increased urine urgency, frequency, bladder fullness, bloody urine, supra-pubic tenderness, flank pain, fever, chills, and malaise (Sihra, et al, 2022). The leukocytes in the dipstick, clinical findings, microscopic hematuria, pyuria, positive nitrite test, and low-grade proteinuria determine UTI. UTI is common in sexually active women, pregnant women, elderly women, and diabetic patients. This is the patient’s primary diagnosis because of symptoms such as dysuria, increased urinary frequency, chills, and rigors. She is a young woman of her reproductive age and sexually active. Hence, she meets the criteria for diagnosis of UTI. Assessing the Genitalia Essay Paper

Pyelonephritis is the acute bacterial infection of the renal parenchyma. It usually ascends from the lower urinary tract. Signs and symptoms of acute pyelonephritis are fever, flank pain, nausea, vomiting, and gross hematuria. Diagnosis of Pyelonephritis depends on nitrite production test, proteinuria, gross hematuria, dipstick leukocyte esterase tests help to screen for pyuria, and ultrasonography to test for nephritis and renal abscess. Acute pyelonephritis is a result of ascending bacterial infection from the lower urinary tract or reaching the kidneys through the bloodstream (Ernstsen, et al, 2022). Pathogens causing pyelonephritis are enterococci, S. aureus, klebsiella, and staphylococcus. Deterioration of acute pyelonephritis may be a complication, unrecognized morbidity, or resistant organism. The patient presents with increased urinary frequency, dysuria, chill, and rigors, making it a probable diagnosis. Laboratory investigations urinalysis and pelvic ultrasound findings will help make the definitive diagnosis.

Pelvic inflammatory disease PID is an inflammatory and infectious disorder of the upper female genital tract including the uterus, fallopian tubes, and the adjacent pelvic structures. Risk factors for PID are multiple sexual partners, previous history of sexually transmitted infections, sexual abuse, vaginal douching, pelvic surgical procedures of the cervix, and contraception such as oral contraceptive pills and intrauterine devices. Causes of PID are ascending infections from the vagina, cervix, to the upper genital tract. The predominant sexually transmitted organisms are chlamydia trachomatis, Neisseria gonorrhea, gardenella vaginalis, and H. influenza (Marcinkowski, et al, 2022). Signs and symptoms are fever, nausea, and vomiting, abdominal pain, abnormal vaginal discharge, post-coital per vaginal bleeding, uterine tenderness, and adnexal tenderness. However, this is not the patient’s diagnosis because she has no vaginal discharge and post-coital per vaginal bleeding.

Cystitis is the inflammation of the bladder caused by a bacterial infection. Presenting signs and symptoms are hematuria, low-grade fever, pelvic discomfort, burning sensation during urination, and increased urgency (Chermansky & Guirguis, 2022). The risk factors are immunosuppression, sexual activity especially for women, and birth control methods such as spermicide.

Chlamydia genitourinary infection is a sexually transmitted infection caused by C trachomatis. It presents with dysuria, vaginal discharge, dyspareunia, fever, lower abdominal pain, and fatigue (Russi, et al, 2022). It is common for patients with multiple sexual partners and engages in unprotected intercourse. Assessing the Genitalia Essay Paper

References

Chermansky, C. J., & Guirguis, M. O. (2022). Pharmacologic Management of Interstitial Cystitis/Bladder Pain Syndrome. Urologic Clinics, 49(2), 273-282.

Ernstsen, C. V., Login, F. H., Schelde, A. S. B., Therkildesen, J. R., Møller‐Jensen, J., Nørregaard, R., … & Nejsum, L. N. (2022). Acute pyelonephritis: increased plasma membrane targeting of renal aquaporin‐2. Acta Physiologica, e13760.

Marcinkowski, K. A., Mehta, V., Mercier, R., & Berghella, V. (2022). Pelvic Inflammatory Disease in Pregnancy: A Systematic Review Focusing on Perinatal Outcomes. American Journal of Obstetrics & Gynecology MFM, 100643.

Russi, R. C., Del Balzo, D., Luján, A., Reidel, I. G., García, M. I., Veaute, C., & Damiani, M. T. (2022). Heterologous prime-boost vaccination based on Polymorphic protein D protects against intravaginal Chlamydia trachomatis infection in mice. Scientific Reports, 12(1), 1-16.

Sihra, N., Malde, S., Greenwell, T., Pakzad, M., Kujawa, M., & Sinclair, A. (2022). Management of recurrent urinary tract infections in women. Journal of Clinical Urology, 15(2), 152-164.

Patients are frequently uncomfortable discussing with healthcare professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam 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 exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions. Assessing the Genitalia Essay Paper

To Prepare

• Review the Episodic note case study (See below).
• Based on the Episodic note case study:
  • Review this week’s 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.
  • Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.
  • Search the 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 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.
    

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  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.

   Episodic note case study

We will look at

• Evaluate abnormal findings on the genitalia and rectum
• Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the breasts, genitalia, prostate, and rectum

The Lab Assignment 

 GENITALIA ASSESSMENT

Subjective:

• CC: dysuria and urinary frequency
• HPI: RG is a 30-year-old female with increase urinary frequency and dysuria that began 3 days ago. Pain is intermittent and described a burning only in urination, but c/o flank pain since last night. Reports intermittent chills and fever. Used Tylenol for pain with no relief. She rates her pain 6/10 on urination. Reports a similar episode 3 years ago.
• PMH: UTI 3 years ago
• PSHx: Hysterectomy at 25 years
• Medication: Tylenol 1000 mg PO every 6 hours for pain
• FHx: Mother breast cancer ( alive) Father hypertension (alive)
• Social: Single, no tobacco , works as a bartender, positive for ETOH Assessing the Genitalia Essay Paper
• Allergies: PCN and Sulfa
• LMP: N/A

Review of Symptoms:

• General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
• Abdominal: Denies nausea and vomiting. No appetite

Objective:

• VS: Temp 100.9; BP: 136/80; RR 18; HT 6’.0”; WT 135lbs
• Abdominal: Bowel sounds present x 4. Palpation pain in both lower quadrants. CVA tenderness
• Diagnostics: Urine specimen collected, STD testing

Assessment:

• UTI
• STD

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. Assessing the Genitalia Essay Paper