Physical Assessment Essay
Case overview
T.S. is a 32-year-old woman complaining of dysuria, frequency, urgency, insomnia, and flank pain. She has not tried anything to help with the discomfort. She had this symptom years ago. She is sexually active and has had a new partner for the past 3 months. She has a history of Tonsillectomy in 2001 and Appendectomy in 2020. She has a low-grade fever, tachycardia, tachypnea, and mild tenderness to palpation in the supra-pubic area. Bimanual pelvic examination reveals a normal-sized uterus and adnexa. There is no adnexal tenderness and vaginal discharge is noted. The cervix appears normal. Her differential diagnoses are UTI and STI. Physical Assessment Essay
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Additional Information That Should Be Included In the Subjective Data and Objective Data
I would ask for more symptoms of the genitourinary system like hematuria, vaginal discharge, and dyspareunia. The age at first intercourse correlates with the risk of STDs. Early-onset sexual intercourse increases the chances of these diseases. The history of contraceptives helps determine STDs. Spermicide and diaphragm increase the risk of sexually transmitted infections compared to other hormonal methods. Ask about sexual preference, practices, and previous STDs. Patients with recurrent STDs have a higher chance of contracting and transmitting other infections. I would examine the eye to check for conjunctivitis, eye swelling, and discharge.
Does the subjective and objective information support the assessment?
The subjective and objective data support the assessment because the patient presents with symptoms of urinary tract infection. However, it is not specific on sexually transmitted diseases because it has not highlighted the patient’s sexual and reproductive health history. Sexually transmitted infection presents with a history of recurrent STDs, multiple sexual partners, oral sores, and mucopurulent discharge.
Appropriate Diagnostic Tests
Serological screening for HIV and VDRL is appropriate to rule out sexually transmitted infections. Urine analysis checks for microscopic hematuria, proteinuria, nitrate test, and pyuria helps confirms the diagnosis of urinary tract infection. Pelvic ultrasounds help in diagnosing pyelonephritis.
Would you reject/accept the current diagnosis?
I would accept the diagnosis as urinary tract infection because the patient presents with dysuria, frequency, urgency, insomnia, and flank pain. She has risk factor for UTI like sexually active and reproductive age. She had similar symptoms years ago. It is not clear if it could be a sexually transmitted infection because she has no symptoms of STI like vaginal discharge. Differential diagnoses are urethritis, cystitis, Pyelonephritis, and Chlamydia genitourinary infection.
Differential Diagnoses
Urinary tract infection is the inflammation of the urethra, bladder wall, and the organs surrounding the urogenital system. Its causes are infestation by fungi, bacteria, and viral pathogens. The common bacterial pathogens causing UTIs are E.coli, Klebsiella, and Enterococcus feacalis. It is more common in women than males because they have a shorter urethra, sexual intercourse, and use of diaphragms and spermicides. Urinary tract infections may be associated with comorbidities like diabetes, previous surgeries, catheterization, previous UTIs, immunosuppressive drugs, and HIV (Neugent, et al, 2019). The signs and symptoms of UTI are dysuria, increased urine urgency and frequency, lower abdominal pain, flank pain, costovertebral tenderness, fever, chills, malaise, and cystitis. Diagnostic tests like microscopic hematuria, proteinuria, nitrate test, and pyuria confirm the diagnosis of urinary tract infection. This is the most probable diagnosis because the patient presents with similar symptoms. Physical Assessment Essay
Acute urethritis is the inflammation of the urethra due to infectious or non-infectious etiologies. The most causes of urethritis are sexually transmitted diseases like gonorrhea and chlamydia trachomatis. The clinical signs and symptoms are discharge, dysuria, itchiness, fever, chills, nausea, sweats, conjunctivitis, and lower back pain (Bartoletti, et al, 2019). A gram stain of the discharge would help determine the diagnosis. Additionally, a urethra swab culture for gonorrhea and trachomatis will help evaluate the cause of the infection.
Cystitis is the inflammation of the bladder particularly in women of reproductive age. It presents with urinary frequency, urgency, incomplete bladder emptying, dyspareunia, pelvic pain, and constant compulsion to void (Kolman, 2019). It has variable periods of exacerbation and remission. Its recurrence in women often fluctuates according to the ovulatory cycle. Other associating symptoms are irritable bowel syndrome, fibromyalgia, vulvitis, and insomnia. There is no specific diagnostic test for cystitis because its etiology is unclear. This is not the patient’s diagnosis because she has no supra-pubic tenderness.
Pyelonephritis is a bacterial infection of the renal parenchyma. The bacteria usually ascend from the lower urinary to the ureters. Common bacterial pathogens are staphylococcus and E. coli. The patient presents with fever, costovertebral pain, nausea, dysuria, abdominal pain, flank fullness, vomiting, gross hematuria, and malaise (Kolman, 2019). The patient presents with similar symptoms. However, it is not the actual diagnosis because the patient denies nausea and vomiting.
Chlamydia genitourinary infection is a sexually transmitted infection affecting the genitalia. It is common in sexually active women of the reproductive age. Risk factors for chlamydia infection are oral sexual intercourse, anal sexual intercourse, poor social-economic status, previous history of STDs, and unprotected intercourse with multiple partners (Yeoh, et al, 2020). The presenting symptoms are vaginal discharge, abnormal vaginal bleeding, dyspareunia, conjunctivitis, adnexal fullness, cervical motion tenderness, and fever. This is not the actual diagnosis because the patient has no adnexal tenderness and vaginal discharge.
Genitourinary Assessment
CC: Increased frequency and pain with urination
HPI:
T.S. is a 32-year-old woman who reports that for the past two days, she has dysuria, frequency, and urgency. Has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months.
Medical History:
None
Surgical History:
Tonsillectomy in 2001
Appendectomy in 2020
Review of Systems: Physical Assessment Essay
General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
Abdominal: Denies nausea and vomiting. No appetite
Objective
VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.
Pelvic Exam:
mild tenderness to palpation in the suprapubic area
bimanual pelvic examination reveals a normal-sized uterus and adnexae
no adnexal tenderness.
No vaginal discharge is noted.
The cervix appears normal.
Diagnostics: Urinalysis, STI testing, Papsmear
Assessment:
UTI
STI
Genitourinary Assessment
CC: Increased frequency and pain with urination
HPI:
T.S. is a 32-year-old woman who reports that for the past two days, she has dysuria, frequency, and urgency. Has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months.
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Medical History:
None
Surgical History:
Tonsillectomy in 2001
Appendectomy in 2020
Review of Systems:
General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
Abdominal: Denies nausea and vomiting. No appetite
Objective Physical Assessment Essay
VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.
Pelvic Exam:
mild tenderness to palpation in the suprapubic area
bimanual pelvic examination reveals a normal-sized uterus and adnexae
no adnexal tenderness.
No vaginal discharge is noted.
The cervix appears normal.
Diagnostics: Urinalysis, STI testing, Papsmear
Assessment:
UTI
STI
THE ASSIGNMENT BELOW
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. Physical Assessment Essay
