Assessing the Genitalia and Rectum
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.
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.
Lab Assignment: Assessing the Genitalia and Rectum
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Lab Assignment: Assessing the Genitalia and Rectum
Subjective Portion
The chief complaint is that the patient, T.S., complains of increased frequency of urination and experiencing pain while urinating. The symptoms have manifested for the past 2 days. The patient confirms not engaging in any intervention so far. She discloses experiencing similar symptoms in the past. T.S. is sexually active and in a 3 months sexual relationship with her partner. She was positively diagnosed with tonsillectomy in 2001 and appendectomy in 2020. She had not noted any weight changes. She is having sleeping difficulties because of flank pain. She feels warm, indicating the possibility of fever. She is neither nauseous nor vomiting but lacks appetite.
Possible additional information to include in the document is the exact duration of the symptoms, the characteristics of pain, voiding patterns, recent changes in sexual behavior, menstrual history, history of kidney stones, previous UTI episodes, recent use of antibiotics and obstetric history. The exact symptom duration requires documentation to provide insights into the progression of the illness. Furthermore, the duration detail will help to determine whether the disease
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