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 inform
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.
GENITALIA ASSESSMENT
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:
· 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
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
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.
RUBRIC FOR GRADING
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. = 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.
Analyze the objective portion of the note. List additional information that should be included in the documentation. = 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.
Is the assessment supported by the subjective and objective information? Why or why not? = 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.
What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis? = The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be use
d to make a diagnosis.
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. 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.
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.= 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.
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation. = Uses correct grammar, spelling, and punctuation with no errors.
This criterion is linked to a Learning OutcomeWritten 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. Uses correct APA format with no errors.
,
Genitourinary Assessment Case Study
NURS 6512: Advanced Health Assessment
Dr. Lenora Wade
August 7th, 2022
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Case Study
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:
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 =99.1F, 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 normal-sized uterus and adnexa
no adnexal tenderness.
No vaginal discharge is noted.
The cervix appears normal.
Diagnostics: Urinalysis, STI testing, Pap smear
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Assessment: UTI, STI
Additional Subjective Data
Gender identity should never be assumed in this day or age. With gender identity, sexual
preferences should be discussed with the patient as well. Some patient’s sexual endeavors
involve inanimate objects that are harmful to the vaginal tissues. Does this patient know how
many sexual partners she has been with? Is she in a monogamous relationship? Has there been
any post-coideal bleeding or dyspareunia? A historical intake of past urinary tract infections
(UTIs), how many, and how were they treated? Any history of sexually transmitted infections
(STI)? Other information to note is the presence or absence of fever, chills, nausea, vomiting
(Ball et al, 2019, p 450).
The Genitourinary section of subjective data should be included with these symptoms.
Urinary symptoms such as dysuria, burning, frequency, and urgency should be further evaluated.
Is the dysuria acute or chronic? Where is the pain located? Does it happen with every single
urination? Does the pain start in the beginning, throughout, or at the end of urination? Does it
feel like the bladder is empty after voiding? Description of the urine can help identify a
hydration, infection, or kidney function status. Description of urine should include color,
presence of blood or particles, and clear or cloudy. Has the patient been experiencing any
nocturia, polyuria, or stress incontinence? Have they noticed any hesitancy, dribbling, or loss in
force of stream during urination? Has the patient noticed any passing of a stone or edema? Flank
pain was mentioned by the patient, but it does specify which side, how far the pain extends,
characteristics of the pain, or any associated factors with the pain. Is there an associated vaginal
symptom such as discharge, or bleeding? Abdominal distention, fullness, pressure, or cramping?
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There is no medical history noted so I assume the patient is not taking any medications,
but it is a good idea to still include ‘no current medications’ in the chart. Diuretics cause changes
in urinary symptoms that could mask or mimic conditions (Ball et al, p 450). Other history to
obtain include information about menstruation. Menarche, interval, duration, amount, and
common symptoms should be discussed. The use of pads versus tampons should also be
addressed. Personal hygiene should also be discussed since many of the symptoms and
conditions being suspected can be caused by poor hygiene. Does she do vaginal douching? Does
she use feminine wash? How does she clean after defecating? Does she urinate after sexual
intercourse?
Additional Objective Data
This provider did mention use of bimanual pelvic exam, but they did not mention the use
of a speculum. The cervix was noted at ‘appears normal’ but I am unsure if this means it was
palpated as normal or visualized with speculum. If it was visualized the color, position, size,
surface characteristics, discharge, and os should be noted. During the bimanual portion, cervical
movement should be nontender. The presence of friable tissue, red patchy areas, granular areas,
or white patches could indicate an infection (Ball et al, 2019, p 450).
Even though the symptoms have to do with the urinary tract, external genitalia should be
examined and palpated. Hair distribution and color should be noted. Labia majora and minora,
clitoris, urethral orifice, vaginal introitus, and perineum should be examined for coloration and
discharge. Any irritation, inflammation, excoriation, caking of discharge in the tissue folds could
be indicative of infection. The clitoris should be examined for size, atrophy, inflammation, or
adhesions. The urethral orifice and perineum should be inspected with special notes on the
presence or absence of polyps, discharge, caruncles, fistulas, inflammation, irritation, or dilation.
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Inspection and palpitation of the Bartholin glands separately should be done as these glands can
get infected as well. The documented bimanual exam should have noted the examination of the
vaginal wall. It should be smooth, homogeneous, and nontender. Its important to keep in mind
vaginal muscle tone and the presence of any cysts, nodules, masses, or growths. Other important
involved organs that were not mentioned is the uterus and ovaries. The uterus size, shape, and
position should be noted. Ovaries are palpable during a bimanual exam. They should be mildly
tender without enlargement or nodules (Ball et al, 2019, p 450). Visual inspection is important
when suspecting a UTI or STI. Palpation of the flank should also be performed and documented
since there is complaints of flank pain. Non-genitourinary exam should include palpation of
lymph nodes and visualization of the mouth and throat.
Is the assessment supported by the subjective and objective information? Why or why not?
Yes, the assessment is supported by the subjective and objective information gathered.
Even though this exam is missing key data helpful in accurately diagnosing. The information
given, such as dysuria, frequency, and urgency, are acceptable to opine UTI but diagnostic
studies are required for an official diagnosis. STI’s are being considered because her symptoms
appeared after a new sexual partner.
Appropriate Diagnostics
Urinalysis (UA) is used to evaluate multiple conditions, especially those that involve the
kidneys. UA can examine the acidity and concentration of urine. It also looks for evidence of
blood, nitrates, protein, ketones, sugar, bilirubin, and infection.
Pap smear is used to check for abnormal cervical cells indicating risk for cervical cancer.
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STI testing to rule out or confirm the presence of a sexually transmitted infection. This is
accomplished in multiple ways, depending on which infection is suspected. These tests can be
taken via blood, urine, or vaginal culture (Behzadi, Behzadi, & Pawlak-Adamska, 2019).
Diagnostic imaging such as an ultrasound, computed tomography (CT), or magnetic resonance
imaging (MRI) are used to visualize, structure, flow, and function. It can help detect physical
anomalies, obstructions, and calculi (Akhavan Sepahi & Mosavimovahed, 2021).
Reject or Accept Diagnosis? Differential Diagnosis
I accept the current diagnosis. Why the subjective and objective exam findings are
missing information. The data that is collected is very typical of a UTI or cystitis. UTI’s are also
a lot more common than my other diagnosis and the patient has had these symptoms in the past.
There is no vaginal discharge or sores noted, which leads me to believe that this condition is not
an STI. The presence of a low-grade fever of 99.1 indicated presence of infection. The
suprapubic tenderness and flank pain point to the reproductive and urinary systems being the site
of infection. This patient did not mention nausea, vomiting, or chills which leads me to believe
the infection has not spread into the kidneys.
Cystitis-is considered a UTI, but more specifically it is an infection of the bladder. Symptoms
include a strong urge to urinate, burning sensation when urinating, frequent urination, hematuria,
pelvic discomfort and pressure, cloudy or strong-smelling urine, and a low-grade fever.
Diagnosed with UA, culture, and diagnostic imaging (Alidjanov et al, 2019).
Hydronephrosis-Swelling of one or more kidneys as a result from buildup of urine. Usually
caused by an obstruction not allowing urine to drain. Symptoms are usually nonspecific and
include nausea, malaise, flank pain, and fever. Headache secondary to hypertension can also
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result from this. Some patients report tea-colored urine or gross hematuria. Examination
findings may include edema, hypertension, and oliguria (Patel & Batura, 2020).
Pyelonephritis-Infection of the kidneys. This results from a kidney stone or a UTI spreading
throughout the urinary tract and up to the kidneys. Symptoms include frequent painful urination,
back and/or groin pain, chills, fever, nausea, and vomiting. Diagnosed with a medical history,
physical exam, UA, culture, ultrasound or CT scan (Johnson & Russo, 2018).
Renal Calculi/Renal Calculi-Mineral deposit buildup in the kidney. Calculi often do not cause
symptoms until they move into a ureter. Symptoms include flank pain, groin/pelvic pain, painful
and burning urination, discolored urine, cloudy urine, persistent urge to urinate, nausea,
vomiting, and fever. Objective findings may include only tenderness to abdomen or groin upon
palpation. Calculi are often diagnosed with a UA, and diagnostic imaging (Ball et al, 2019, p
450).
Sexually Transmitted Infection-This can include Gonorrhea, Chlamydia, Trichomoniasis, or Type
2 Herpes Simplex. Gonorrhea often infects the urethra, rectum, or throat. Symptoms include
painful urination, increased vaginal discharge, abnormal vaginal bleeding, and abdominal or
pelvic pain. Chlamydia symptoms include painful urination, abnormal vaginal bleeding, foul
smelling discharge, or sores. Type 2 Herpes Simplex symptoms include sores, fever, swollen
lymph nodes, body aches, headache, decreased appetite, and pain at the site of infection.
Trichomoniasis is an infection caused by a parasite. Most people infected have little or no
symptoms. If symptoms are present, they can include itching, burning, redness, and tenderness
of the genitals, painful urination, and foul-smelling vaginal discharge. Laboratory tests and
cultures are used to diagnose STI’s (Olson et al, 2021).
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Resources
Akhavan Sepahi, M., & Mosavimovahed, M. (2021). Best Imaging Method for Detection of
Renal Stones. Medical journal of the Islamic Republic of Iran, 35, 160.
https://doi.org/10.47176/mjiri.35.160
Alidjanov, J. F., Naber, K. G., Abdufattaev, U. A., Pilatz, A., Wagenlehner, F. M. (2019).
Reliability of symptom-based diagnosis of uncomplicated cystitis. Karger, 102(1), 83-95.
https://doi.org/10.1159/000493509
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to
physical examinations: An interprofessional approach (9th ed.). St. louis, MO: Elsevier
Mosby.
Behzadi, P., Behzadi, E., & Pawlak-Adamska, E. A. (2019). Urinary tract infections (UTIs) or
genital tract infections (GTIs)? It's the diagnostics that count. GMS hygiene and infection
control, 14, Doc14. https://doi.org/10.3205/dgkh000320
Johnson, J. R & Russo, T. A. (2018). Acute pyelonephritis in adults. New England Journal of
Medicine, 378, 48-59. 10.1056/NEJMcp1702758
Olson, E., Gupta, K., Van Der Pol, B., Galbraith, J. W., & Geisler, W. (2021). Mycoplasma
genitalium infection in women reporting dysuria: A pilot study and review of the
literature. International Journal of STF and AIDS, 32(13).
https://doi.org/10.1177/09564624211030040
Patel, K. & Batura, D. (2020). An overview of hydronephosis in adults. British Journal of
Hospital Medicine, 81(1). https://doi.org/10.12968/hmed.2019.0274
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