Evaluate Abnormal Findings on the Genitalia and Rectum Comprehensive Nursing Paper Sample

Evaluate Abnormal Findings on the Genitalia and Rectum Comprehensive Nursing Paper Sample

Genital and rectum examinations are critical for patients who present specific systems or are a part of a health visit. Genitourinary concerns can complicate a patient’s health, and a focused and comprehensive history is critical for definitive examination and diagnosis. Therefore, appropriate nursing skills are critical for the appropriate assessment and diagnosis of presented symptoms. This paper discusses a genitourinary assessment, providing additional subjective and objective data and an opinion on whether the assessment was founded on subjective and objective information. Moreover, the paper discusses the current diagnosis and differential diagnoses.(Evaluate Abnormal Findings on the Genitalia and Rectum Comprehensive Nursing Paper Sample)

Additional Subjective Data

Additional subjective information that should be documented in this assessment includes the history of flank pain and the associated characteristics. Different conditions, including UTIs and Kidney stones, can cause flank pain. Gynecologic history, including information on the date of last pelvic examination, pap smears, and vaginal infections, could support the diagnosis. Furthermore, additional information on cigarette smoking and diseases such as HIV and pulmonary inflammatory disease are necessary since they are associated with risks of urination frequency, dysuria and urinary frequency. Information on previous vaginal discharge or odour is critical since they indicate infections. Lastly, the physician should have asked for additional information on the patient’s sexual history, including the number of sexual partners and other sexual practices, since urethritis associated with dysuria and urinary frequency are associated with STI. (Evaluate Abnormal Findings on the Genitalia and Rectum Comprehensive Nursing Paper Sample)

Additional Objective Data

            Additional objective information that should be documented in this assessment includes the patient’s general appearance of gastrointestinal and genitourinary assessments. The physician should have assessed the patient for inflammation, irritation, or discharger, suggesting poor hygiene, foreign objects insertion, or vaginal infection (Ball et al., 2019). Equally, the presence of vesicles or ulcers could be signs of STIs. It is also necessary to genitourinary exam to provide information on vaginal bleeding, cervix tenderness, and foul smell. Lastly, information on the presence of rectal lesions, masses, and trauma are necessary to establish since they are usually associated with urination frequency and dysuria. (Evaluate Abnormal Findings on the Genitalia and Rectum Comprehensive Nursing Paper Sample)

Does Subjective and Objective Information Support the Assessment?

The assessment is partially supported by subjective and objective information. The patient is diagnosed with a UTI or STD. The patient presents symptoms associated with UTI, including frequent urination, dysuria, and flank pain (Tan & Chlebicki, 2016). However, the assessment does not provide meaningful information related to UTI diagnoses such as urine smell, bladder spasm, urine characteristics, vaginal irritation, and malaise/fatigue. Therefore, there is a need to provide additional information to determine whether UTI is the definitive diagnosis.  (Evaluate Abnormal Findings on the Genitalia and Rectum Comprehensive Nursing Paper Sample)

Furthermore, the patient presents specific symptoms associated with STDs, including lower abdominal pain and dysuria. However, the assessment fails to provide information on acute symptoms associated with STD, including vaginal discharge or bleeding, skin characteristics, foul discharge, sores, and swollen lymph nodes (Garcia & Wray, 2021). Significantly, the physician should have provided information on the collected urine specimens and STD testing results to ascertain the type of UTI or STD.(Evaluate Abnormal Findings on the Genitalia and Rectum Comprehensive Nursing Paper Sample)

Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?

The most appropriate diagnostics for this case are Urinalysis and urine PCR tests. Urinalysis and urine PCR tests are good diagnostic tools for testing STDs and UTIs. The tests can detect a wide range of UTIs and STDs and the causal conditions. The urine PCR test can detect bacterial and parasitical DNA critical to ascertaining the pathogenic cause of an STI.(Evaluate Abnormal Findings on the Genitalia and Rectum Comprehensive Nursing Paper Sample)

Would you reject/accept the current diagnosis? Why or why not?

I would accept the current diagnosis. The patient presents critical UTI or STD diagnosis symptoms, including dysuria and urinary frequency, flank pain, intermittent fever, and chills. The patient’s history of UTI and hysterectomy are also risk factors for recurrent UTI. However, a diagnostic test is necessary to ascertain the actual cause.(Evaluate Abnormal Findings on the Genitalia and Rectum Comprehensive Nursing Paper Sample)

Identify three possible conditions that may be considered a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

1. Renal calculi: Kidney stones can form in the pelvis leading to the infection and obstruction of the urinary tracts (Ball et al., 2019). As a result, individuals experience flank pain and frequent and painful urination symptoms.
2. Cystitis: Cystitis is an infection of a section of the urinary tract, bladder, kidney, or urethra (Li & Leslie, 2021). Symptoms include frequent and painful urination and lower abdominal pain, among other symptoms.
3. Trauma associated with sexual intercourse: Trauma from sexual experiences can mediate stress-induced response urinations leading to urinary dysfunction (Boyd et al., 2020). Symptoms associated with trauma due to sexual intercourse are varied and include abnormal frequency and painful urination.(Evaluate Abnormal Findings on the Genitalia and Rectum Comprehensive Nursing Paper Sample)

References

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.(Evaluate Abnormal Findings on the Genitalia and Rectum Comprehensive Nursing Paper Sample)

Boyd, B. A., Gibson, C. J., Van Den Eeden, S. K., McCaw, B., Subak, L. L., Thom, D., & Huang, A. J. (2020). Interpersonal trauma as a marker of risk for urinary tract dysfunction in midlife and older women. Obstetrics and gynaecology, 135(1), 106. https://dx.doi.org/10.1097%2FAOG.0000000000003586

Garcia, M. R., & Wray, A. A. (2021). Sexually transmitted infections. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK560808/

Li, R., & Leslie, S. W. (2021). Cystitis. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK482435/ Tan, C. W., & Chlebicki, M. P. (2016). Urinary tract infections in adults. Singapore medical journal, 57(9), 485. https://dx.doi.org/10.11622%2Fsmedj.2016153