Episodic Note: Genitalia Assessment

Episodic Note: Genitalia Assessment

Subjective Portion Analysis

The case presents a 32-year-old with a history of dysuria, frequency, and urgency for two days. These are symptoms that are localized to the genitourinary system. In evaluating the patient, extensive inquiry should be done on the GUT system during history taking. It is important to find out more about the reported dysuria in terms of onset if it is acute. Also, it should be established if the pain is only on the flanks or radiates to other parts of the abdomen. The flank pain should be established, whether it is throbbing or stabbing, and its severity should be determined on a scale of 1-10. Knowing what aggravates or relieves the flank pain, dysuria, and frequency will be important.

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The patient should also provide information regarding the urine produced and if there is any change in color, smell, and the amount of urine produced. Evaluating these aspects is essential to determine the hydration status of the patient as well as a rule in other differential diagnoses such as urinary tract infections. Other important aspects to be determined include her gynecological history, where her last normal menstrual period should be asked. This will help find out if she is pregnant or not. Lastly, asking about her sexual history is important. Much as she reports having a new partner for three months now, she should report her sexual partners (number) if she is in a monogamous/polygamous relationship, any history of post-coital bleeding, and any history of treatment for sexually transmitted infections (STIs).

Objective Portion Analysis

In the objective evaluation of this patient, the examination has been limited to the pelvic region partly because the patient’s reported symptoms suggest that the pathology arises from the GUT. However, evaluating other systems such as HEENT, cardiovascular, respiratory, gastrointestinal, and musculoskeletal systems is also essential. The holistic approach of a patient during a presentation with symptoms of illness may help detect other pathologies in other systems of which the patient may not be aware.

The suprapubic region has been examined, and there is a report of mild tenderness; there should be an explanation if this was elicited during superficial or deep palpation and if there is any mass palpated. The examiner has done a bimanual pelvic exam and reports the normal size of the uterus and adnexa, which is perfect. However, it should be noted that when describing the cervix as normal, the examiner should report that a speculum exam has been done to visualize the cervix.

Other essential parts in evaluating a patient with GUT complaints are examining her external genitalia and assessing her hair distribution, labia majora/minora, the vulva, abnormal skin changes, ulceration, irritation, or discharge. This will help make an impression of some STIs that cause skin ulceration or any abscesses within the genitourinary regions, such as the Bartholin gland abscess. Other pathologies to be examined include fistulas, polyps, or irritation, especially along the urethral orifice. When doing the bimanual exam, the examiner should report about the vaginal wall if it is smooth and pink in color. The choice of diagnostics, including urinalysis, STI testing, and pap smear, has been done well.

Is the Assessment Supported by the Subjective and Objective Information?

Yes, the assessment is supported by the subjective and objective portions. The evaluation provided two diagnoses, urinary tract infection and sexually transmitted infection. The two are GUT pathologies, and the subjective portion provides a history of dysuria, frequency, urgency, prior history of the same symptoms years ago, being sexually active, and having a new partner for three months. Either of these may explain any of the above assessment findings. Her objective portion provides suprapubic tenderness and normal uterus/adnexa, and her diagnostics are appropriate for the assessment findings.

 

 

 

Are the Diagnostics Appropriate?

Yes.

Urinalysis (U/A): This test evaluates for abnormal findings in urine ranging from PH, presence/absence of blood/pus cells, casts, and nitrites. It may also establish if glucose or proteins is leaking into urine. Therefore, this test is necessary to establish the presence of an infection and is a routine test done in patients with GUT complaints. The presence of nitrites, pus cells, and blood cells in urine highly suggests that there is a urinary tract infection (Bono & Reygaert, 2022).

STI testing: This will establish the presence of a sexually transmitted infection and can be done through blood, urine, or high vaginal swabs for microscopy/culture/sensitivity. VDRL (Venereal Disease Research Laboratory) and RPR (Rapid Plasma Reagin) tests are crucial if syphilis is suspected (Garcia & Wray, 2021). A positive vaginal swab may rule in gonorrhea, an STI.

Pap smear: Cells are obtained from the transformation zone to establish any possibility of a malignancy that can be responsible for the presenting symptoms (Kitchen & Cox, 2018). A pap smear detects cervical cancer if positive.

Other diagnostic studies that will be of value in this patient include ultrasound of the kidneys, ureters, and bladder (KUB), which is a rapid and affordable test that can evaluate the anatomy of the above organs and detect any pathology such as renal calculi (Grogan & Mount, 2021). Other include computerized tomography (CT scan) and magnetic resonance imaging (MRI) to visualize the flow and functions of GUT organs.

Reject/Accept Current Diagnosis?

I am accepting the current diagnosis of UTI. The patient possibly has an uncomplicated UTI, which presents with dysuria, frequency, hesitancy, urgency, and hematuria, and she has most of the symptoms in her presenting complaints (Bono & Reygaert, 2022). She has no history of fever, chills, nausea, or vomiting. Therefore, the infection may not have spread to the kidneys. I also accept the diagnosis of an STI. STIs present with painful/burning urination, smelly vaginal discharge, lower abdominal pain, and fever (Garcia & Wray, 2021). However, in the patient’s case, she has suprapubic pain, possibly due to bladder involvement and flank pains pointing towards a pathology involving the kidneys. This, therefore, makes a UTI more possible compared to STI.

Differential Diagnosis

Cystitis

Refers to urinary bladder inflammation due to a bacterial infection (Lala & Minter, 2019). It presents with frequency, urgency, painful/burning sensation with micturition, pelvic discomfort, low-grade fever, hematuria, and smell of urine with a color change (Lala & Minter, 2019). Diagnosis is through U/A, culture/sensitivity, and imaging through cystoscopy to visualize the bladder.

Acute Pyelonephritis

Refers to inflammation of the kidneys due to an infectious process of bacterial origin (Belyayeva & Jeong, 2022). The pathology is due to complicated bladder infection/inflammation that ascends the ureter to involve the kidneys. Clinical features include dysuria, back/groin pain, fever, chills, nausea, and vomiting. Diagnosis is through comprehensive medical history, UA, bacterial culture/sensitivity, and imaging through KUB ultrasound to identify pathology in ureters, bladder, or kidneys.

Renal Calculi/Stones

These are mineral deposits that accumulate in the kidneys, ureters, or bladder. They become symptomatic when they lodge within the ureters. Presenting features include flank pains, painful/burning urination, cloudy urine, nausea, vomiting, frequency, urgency, and fever (Leslie et al., 2019). Renal calculi are a common cause of recurrent urinary tract infections as they cause stasis of urine with the GUT system, increasing the risk of bacterial infection (Leslie et al., 2019).

Pelvic inflammatory disease (PID)

PID is a complication of STIs. Common STIs include gonorrhea, syphilis, chlamydia, herpes simplex, and trichomoniasis. Gonorrhea infection presents with dysuria, vaginal discharge, vaginal bleeding, and pelvic pain (Garcia & Wray, 2021). Chlamydia presents with abnormal vaginal bleeding, smelly discharge, dysuria, and sores. Herpes simplex type 2 is associated with painful sores, fever, body aches, and lymphadenopathy (Garcia & Wray, 2021). Trichomonas infection presents with dysuria, smelly discharge, and a burning sensation around the genitals.

Hydronephrosis 

Refers to swelling of the kidneys due to urine accumulation. The accumulation is due to an obstruction along the GUT system (Thotakura & Anjum, 2020). Clinical presentation includes flank pain, fever, nausea, and vomiting. Patients may have headaches due to hypertension (Thotakura & Anjum, 2020). Urine may be tea-colored or contain blood. Upon examination, patients have edema, oliguria, and hypertension.

 

 

 

 

 

 

 

 

 

References

Belyayeva, M., & Jeong, J. M. (2022, September 18). Acute pyelonephritis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519537/

Bono, M. J., & Reygaert, W. C. (2022). Urinary tract infection. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470195/

Garcia, M. R., & Wray, A. A. (2021). Sexually Transmitted Infections. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560808/

Grogan, S. P., & Mount, C. A. (2021, April 7). Ultrasound Physics and Instrumentation. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK570593/

Kitchen, F. L., & Cox, C. M. (2018). Papanicolaou Smear. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470165/

Lala, V., & Minter, D. A. (2019). Acute Cystitis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459322/

Leslie, S. W., Hussain Sajjad, & Murphy, P. B. (2019, October 8). Renal Calculi. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK442014/

Thotakura, R., & Anjum, F. (2020). Hydronephrosis And Hydroureter. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK563217/

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Post the Episodic note case study: Genitalia Assessment in the “Course Announcements” section of the course. Students will need this case study to complete the Lab Assignment for this week. You can find the Episodic note case study: Genitalia Assessment listed below.

You do not need to re-copy the case study. Do not submit more than five pages.

 

  • Based on the Episodic note case study:
    • Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.
    • Search the Walden Library or the Internet for evidence-based resources to support your answers to the questions provided.
    • Consider what history would be necessary to collect from the patient in the case study.
    • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
    • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
    • 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.

Genitourinary Assessment

CC: Increased frequency and pain with urination

HPI:

T.S. is a 32-year-old woman who reports that she has had dysuria, frequency, and urgency for the past two days. She has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has had a new partner for three 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, Pap smear

Assessment:

  • UTI
  • STI

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be needed for future courses.

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