Case Study Review Genitalia Assessment

Case Study Review Genitalia Assessment

Genitalia Assessment

The assigned case study demonstrates a 30-year-old female patient with a chief complaint of dysuria and urine frequency. The patient reports that these symptoms started about three days ago. Associated symptoms include flank pain, burning sensation when urinating, chills, and fever. She has been using Tylenol to manage the pain with no success. Her urine specimen was collected to test for UTI, in addition to STD testing. The purpose of this paper is to analyze and provide additional subjective and objective data, necessary to promote a patient’s diagnosis.

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Additional Subjective Data

Based on the patient’s history, it was necessary to collect more information regarding the patient’s chief complaints to avoid instances of misdiagnosis, especially for sexually transmitted infections. For instance, the patient should explain whether the painful urination and increase in urine frequency have worsened ever since it started (Barrow et al., 2020). She also needs to provide information regarding her menses, whether they are regular or irregular. Consequently, she needed to clarify whether she has had similar symptoms in the past, in addition to the last time she visited a gynecologist for a pelvic examination.

Additional Objective Data

            The objective data portion of the patient history also needs more information to confirm the primary diagnosis and dismiss differentials. Reporting only on the characteristic of the pain is not enough. The odor and quantity among other characteristics of her virginal discharge should also be examined (Chu &Lowder, 2018). It is also necessary to determine the pH of the discharge. Assessment of cervical motion tenderness is also essential to rule out pelvic inflammatory disease.

Diagnostic Exams

Diagnostic studies such as nucleic acid amplification test (NAAT) or culture are necessary to determine whether the patient’s symptoms result from gonorrhea, chlamydia, or other sexually transmitted infection in addition to the previously ordered urinalysis (Barrow et al., 2020). Wet preparation (10% KOH, saline) is also necessary to rule out the diagnosis of trichomoniasis. Additional diagnostic tests include HIV test, presence of WBC on saline microscopy of the discharge, gram stain, pap smear, and HPV test.

Differential Diagnosis

The most probable differential diagnoses are UTI, acute pyelonephritis, and chlamydia based on the patients presenting symptoms. These are the most common genealogical conditions among young female adults with a chief complaint of dysuria. Patients diagnosed with UTI  will present with symptoms such as burning sensation when urinating, increased urine frequency and urgency, fever, flank pain and chills just as displayed by the patient provided in the above case study (Chu &Lowder, 2018). However, urinalysis is needed to confirm this diagnosis. Chlamydia, on the other hand,is also associated with painful urination, and abdominal pain (Barrow et al., 2020). However, the patient has failed to mention abnormal discharge which is a key factor in the diagnosis of this condition. Acute pyelonephritis on the other hand is also associated with painful flank, increased urgency and urine frequency, fever, and chills just as displayed in the patient described above (Herness et al., 2020). However, most of these patients will also present with nausea and vomiting which are negative in the present patient.

Conclusion

            The patient in the provided case study presents with signs of gynecological infection, either a UTI or an STD as demonstrated in the assessment. However, additional objective and subjective data are needed to confirm this diagnosis. Consequently, additional lab tests must be ordered to confirm the primary diagnosis and rule out differentials.

References

Barrow, R. Y., Ahmed, F., Bolan, G. A., &Workowski, K. A. (2020). Recommendations for providing quality sexually transmitted diseases clinical services, 2020. MMWR Recommendations and Reports, 68(5), 1. https://doi.org/10.15585/mmwr.rr6805a1

Chu, C. M., &Lowder, J. L. (2018). Diagnosis and treatment of urinary tract infections across age groups. American journal of obstetrics and gynecology, 219(1), 40-51. https://doi.org/10.1016/j.ajog.2017.12.231.

Herness, J., Buttolph, A., & Hammer, N. C. (2020). Acute pyelonephritis in adults: rapid evidence review. American Family Physician, 102(3), 173-180.PMID: 32735433

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Assignment:

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.

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

 

Rubric:

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.—

 

• 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?—

 

 

• What diagnostic tests would be appropriate for this case, and how would the results be used 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.—

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.—

Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation—

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.—

 

Patient information to Analyze

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
• 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.