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.

To Prepare

· Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.

1. Case Study Assignment  This week you will be reviewing another SOAP      note and reflecting on the additional information that you would be      needing.  This is not in SOAP format,      you will use headings for each section, and give me dialogue on what      information is missing in each section.  You will provide 5      differentials and reflect on the questions posed for the assignment.       Be sure to support with scholarly references.

Special Examinations—Breast, Genital, Prostate, and Rectal GENITALIA ASSESSMENT

Subjective:•

CC: “I have bumps on my bottom that I want to have checked out.”

•HPI: AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner during the past year. Her initial sexual contact occurred at age 18. She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.

•PMH: Asthma•Medications: Symbicort 160/4.5mcg •Allergies: NKDA

•FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD

•Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:•VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs•Heart: RRR, no murmurs•Lungs: CTA, chest wall symmetrical•Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia•Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, neg McBurney•Diagnostics: HSV specimen obtained

Assessment: •Chancre

In summary, be sure to follow the rubric for this assignment.  Tell me what is missing in each section…..and would you support or refute the diagnosis.  Support that answer with rationale, and provide differential diagnosis with supported rationale.  Utilize scholarly references to support your rationales.  Remember….if you are doing a focused exam, which is what these case studies are…..be sure to really expand on the body systems that you are concerned about to hone in on your differential diagnosis.  This will help you with your documentation completeness going forward.

· Based on the Episodic note case study:

o 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.

o Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.

o Consider what history would be necessary to collect from the patient in the case study.

o 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?

o Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

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.

USW1.39745.202130 – NURS-6512N-34,Advanced Health Assessment.2020 Winter Qtr 11/30-02/21-PT27

SafeAssign Drafts

Afolabi Adegbite
on Sun, Feb 07 2021, 10:28 AM

60% highest match

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Citations (12/12)

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Another student’s paper

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https://domynursingessay.com/analyze-the-subjective-portion-of-the-note-list-additional-information-that-should-be-included-in-the-documentation-2/

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Another student’s paper

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Another student’s paper

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https://allroundessays.com/analyze-the-objective-portion-of-the-note-list-additional-information-that-should-be-included-in-the-documentation/

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Another student’s paper

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Another student’s paper

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Another student’s paper

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Another student’s paper

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Another student’s paper

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Running Head: ASSESING GENITALIA AND RECTUM 1
ASSESING GENITALIA AND RECTUM 2

1
Assessing Genitalia and Rectum

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Assessing Genitalia and Rectum

Source – Another student’s paper
Assessing the Genitalia and Rectum

Afolabi Adegbite
Walden University
NURS 6512N:

2
Advanced Health Assessment and Diagnostic Reasoning

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Advanced Health Assessment and Diagnostic Reasoning

Source – Another student’s paper
Advanced Health Assessment and Diagnostic Reasoning

Kimberly Olszewski
February01, 2020

1
ASSESING GENITALIA AND RECTUM

Suspected Entry: 65% match

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ASSESING GENITALIA AND RECTUM

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Assessing the Genitalia and Rectum

3
Analyze the subjective portion of the note.

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Analyze the subjective portion of the note

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Analyze the subjective portion of the note

List additional information that should be included in the documentation.

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List additional information that should be included in the documentation

Source – https://domynursingessay.com/analyze-the-subjective-portion-of-the-note-list-additional-information-that-should-be-included-in-the-documentation-2/
List additional information that should be included in the documentation

· Investigation is a crucial part of treatment. Looking at this case study, the subjective portion of the SOAP note is not complete. The subjective portion is an integral part of the assessment because it carries the patient’s illness history.

4
Since this is a genitalia assessment, the sexual practices before and after the bump’s appearance are very vital.

Suspected Entry: 62% match

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Since this is a genitalia assessment, the sexual practices before and after the bump’s appearance are very vital

Source – Another student’s paper
Bearing in mind that this is a genitalia assessment, it is important to assess the patient’s sexual practices and history before the bump’s appearance

The physician must assess the patient regarding safe sex practices. Some of the questions that must be addressed include.
· Do you use protection during sex?
· Are you involved in male or female sexual practices or both?
· Have you recently subjected that area to any kind of trauma, such as shaving?
· Did you try any remedy for treating the bump using any medication or any other traditional method?

3
Analyze the objective portion of the note.

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Analyze the objective portion of the note

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Analyze the objective portion of the note

List additional information that should be included in the documentation.

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List additional information that should be included in the documentation

Source – https://domynursingessay.com/analyze-the-subjective-portion-of-the-note-list-additional-information-that-should-be-included-in-the-documentation-2/
List additional information that should be included in the documentation

The note’s objective part is critical as it helps give a piece of detailed information to match the patient’s subjective symptoms.

4
Since there are positive findings in the external labia, it is crucial to examine the area.

Suspected Entry: 63% match

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Since there are positive findings in the external labia, it is crucial to examine the area

Source – Another student’s paper
There are positive findings in the external labia, which shows the importance of examining the area

The patient has to be assessed for inflammation and swelling, and the physician has to inquire whether the patient has any irritation.

Suspected Entry: 92% match

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The patient has to be assessed for inflammation and swelling, and the physician has to inquire whether the patient has any irritation

Source – Another student’s paper
The patient has to be assessed for inflammation and swelling and inquire whether the patient has any irritation

Unilateral swelling of the labia may be an indication of Bartholdi gland infection.

Suspected Entry: 66% match

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Unilateral swelling of the labia may be an indication of Bartholdi gland infection

Source – Another student’s paper
If the patient has unilateral swelling of the labia, this might indicate that there may Bartholdi gland infection

For proper evaluation of infection on the physical exam, the Skene glands need to be evaluated through milking properly. It would also be critical to palpate internally to assess any possibility of internal symptoms such as fistulas. Proper evaluation is the only way to rule out any condition that a patient may be having.

4
It is known that most vaginal infections come from the anus then being transferred to the rectum.

Suspected Entry: 65% match

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It is known that most vaginal infections come from the anus then being transferred to the rectum

Source – Another student’s paper
Most vaginal infections originate from the anus and then transferred to the rectum because of the close anatomical closeness

This is because of the anatomical closeness between the two.

4
It is, therefore, essential to perform a full rectum and anus inspection.

Suspected Entry: 66% match

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It is, therefore, essential to perform a full rectum and anus inspection

Source – Another student’s paper
This, therefore, explains why it is very important to perform a full anus and rectum infection

A full-body skin examination is also critical when performing a genitalia assessment.
It is critical to look closely at sores on the mouth, hands, and feet during the assessment. These may help in evaluating other signs of disease. The patient who is suspected of having an STD requires neurological and lymph examination (Wald, 2018). These systems are affected by these diseases, and thus, some symptoms of sexually transmitted diseases may be seen in these systems.

3
Is the assessment supported by subjective and objective information?

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Is the assessment supported by subjective and objective information

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Is the assessment supported by the subjective and objective information

Why or why not?

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Why or why not

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Why or why not

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Objective and subjective data support this assessment.

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Objective and subjective data support this assessment

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Whether objective and subjective data support the assessment

This is so because the patient is presenting with positive findings in the external labia. Positive findings in the outer labia may indicate that the patient has a sexually transmitted disease. Similarly, this can be supported by the fact that this patient confirms sleeping with multiple sexual partners without protection during these acts. This patient’s history also supports this because it shows that the patient has had a sexually transmitted disease. All these factors put the patient at very significant risk of contracting an STD.

6
Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?

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

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

Diagnostic testing is the only sure way of knowing the disease that the patient may be suffering from. A diagnostic test will help to narrow down to the most probable diagnosis.

4
To understand if there is any virus in this patient’s body, the physician is required to do a herpes simplex virus test.

Suspected Entry: 62% match

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To understand if there is any virus in this patient’s body, the physician is required to do a herpes simplex virus test

Source – Another student’s paper
Herpes simplex virus specimen will help determine if there is the presence of a virus in the patient’s body

This is a blood test that screens for genital herpes infection among patients that present with sores.
The patient should also be subjected to rapid plasma regain. This is a syphilis blood test that helps in looking for antibodies to syphilis bacteria.

4
This is done by detecting the number o specific antibodies produced by the body while fighting for infections.

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This is done by detecting the number o specific antibodies produced by the body while fighting for infections

Source – Another student’s paper
This test helps in detecting the number of specific antibodies that the body produces while fighting for infections

She must also be subjected to HI test, gonorrhea, and Chlamydia. If all these tests turn out negative, the physician must undertake a biopsy on the bump to help rule out the patient’s possibility of vulva cancer.

3
Would you reject/accept the current diagnosis?

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Would you reject/accept the current diagnosis

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Would you reject/accept the current diagnosis

Why or why not?

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Why or why not

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Why or why not

I would accept the current diagnosis.

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I would accept the current diagnosis

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Would you reject/accept the current diagnosis

5
A chancre is a painless genital ulcer that, in most cases, is formed during the early stages of syphilis (Rowley, et al., 2019).

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A chancre is a painless genital ulcer that, in most cases, is formed during the early stages of syphilis (Rowley, et al., 2019)

Source – Another student’s paper
The first stage is called primary syphilis, and it is characterized by a painless ulcer known as a chancre (Rowley et al., 2019)

7
Syphilis is transmitted through unprotected sexual contact with infected people.

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Syphilis is transmitted through unprotected sexual contact with infected people

Source – Another student’s paper
Syphilis is transmitted through unprotected sexual contact with an infected person

4
This means that it should be suspected in patients who have unprotected sexual intercourse with multiple partners.

Suspected Entry: 94% match

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This means that it should be suspected in patients who have unprotected sexual intercourse with multiple partners

Source – Another student’s paper
This means that it should e suspected in patients who have unprotected sexual intercourse with multiple partners

This patient has admitted having various sexual partners and never uses protection.

4
Syphilis must be detected and treated early enough.

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Syphilis must be detected and treated early enough

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Syphilis must be detected and treated early enough

If left unchecked for long, it can cause neurological, musculoskeletal, and hepatic severe damages.

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If left unchecked for long, it can cause neurological, musculoskeletal, and hepatic severe damages

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If left unchecked for long, it can cause neurological, musculoskeletal, and hepatic severe damages

Therefore, looking at the signs and symptoms presented by this patient, she is in the early stages of syphilis, and thus the current diagnosis fits this patient.
Differential diagnosis
Genital herpes
Genital herpes disease is transmitted through skin to skin contact with an infected person.

4
Individuals with this condition have painful genital, cervix, or anal erythematous sores.

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Individuals with this condition have painful genital, cervix, or anal erythematous sores

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Genital herpes The persons who have this condition will have a painful genital, cervix, or anal erythematous sores (Gnann & Whitley, 2016)

They also present with other symptoms such as swollen lymph nodes, which accompany sores during the initial outbreak, and headaches.

Suspected Entry: 65% match

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They also present with other symptoms such as swollen lymph nodes, which accompany sores during the initial outbreak, and headaches

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The patients will experience headache, have swollen lymph nodes which accompany sores during the initial outbreak

This condition will typically come as a group of sores, and in rare cases, will they occur solely in one place.

Suspected Entry: 68% match

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This condition will typically come as a group of sores, and in rare cases, will they occur solely in one place

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The disease normally comes as a group of sores, and in rare cases, will they occur solely in one place, thus making this diagnosis more unlikely

The fact that the sores in this condition occur as a group makes this diagnosis more unlikely.
Bartholin Cryst

4
The Cryst is ordinarily painless, and it is tender.

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The Cryst is ordinarily painless, and it is tender

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The Cryst is normally painless, and it is tender

A full-blown infection occurs in a matter of a few days after the infection.

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A full-blown infection occurs in a matter of a few days after the infection

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A full-blown infection occurs in a matter of a few days (Silman et al., 2018)

If the Cryst is infected, the patient experiences a tender, painful lump near the vaginal opening (Moscovitz, et al., 2017).

Suspected Entry: 84% match

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If the Cryst is infected, the patient experiences a tender, painful lump near the vaginal opening (Moscovitz, et al., 2017)

Source – Another student’s paper
If the Cryst is infected, the patient experiences a tender, painful lump near the vaginal opening

The patient will feel uncomfortable while walking or sitting.

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The patient will feel uncomfortable while walking or sitting

Source – Another student’s paper
one is uncomfortable while walking or sitting

The patients with this condition also report having painful sexual intercourse. They also report having a fever. This condition is in most cases reported to women who are in their twenties.

4
The Cryst is filled with fluid.

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The Cryst is filled with fluid

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The Cryst is filled with fluid, which disqualifies this differential diagnosis

These signs and symptoms presented with a person with this condition do not fit with our patient. Therefore, this differential diagnosis is most unlikely.
Vulva cancer
Vulva cancer is not a common disease as it only accounts for four percent of all female reproductive cancers.

4
It starts as a painless lump on the vulva.

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It starts as a painless lump on the vulva

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Vulva cancer appears as a painless lump on the vulva

The lump may be accompanied wit pruritis from the vaginal irritation (Hinten et al., 2017).

Suspected Entry: 72% match

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The lump may be accompanied wit pruritis from the vaginal irritation (Hinten et al., 2017)

Source – Another student’s paper
The lump may be accompanied by pruritis from the vaginal irritation

The patient may have a change of the skin color of the vulva.

Suspected Entry: 96% match

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The patient may have a change of the skin color of the vulva

Source – Another student’s paper
The patient may have a change in the skin color of the vulva

It is crucial to conduct a vulva biopsy for a definitive diagnosis.

4
It is the women above the ages of 50 who are at a greater risk of contracting this disease.

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It is the women above the ages of 50 who are at a greater risk of contracting this disease

Source – Another student’s paper
The women above the ages of 50 are at a greater risk of contracting this disease, therefore not consistent with this particular patient

The signs and symptoms that this patient presents are not consistent with those presented by this patient.
References

1
Hinten, F., Molijn, A., Eckhardt, L., Massuger, L.

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Hinten, F., Molijn, A., Eckhardt, L., Massuger, L

Source – Another student’s paper
Hinten, F., Molijn, A., Eckhardt, L., Massuger, L

F., Quint, W., Bult, P.,.

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F., Quint, W., Bult, P.,

Source – Another student’s paper
G., Quint, W., Bult, P.,

& de Hullu, J.

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& de Hullu, J

Source – Another student’s paper
& de Hullu, J

A. (2017). VULVAR CANCER:

1
TWO PATHWAyS WITH DIFFERENT LOCALIZATION AND PROGNOSIS.

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TWO PATHWAyS WITH DIFFERENT LOCALIZATION AND PROGNOSIS

Source – Another student’s paper
two pathways with different localization and prognosis

8
PDF hosted at the Radboud Repository of the Radboud University Nijmegen, 39.

Suspected Entry: 93% match

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PDF hosted at the Radboud Repository of the Radboud University Nijmegen, 39

Source – Another student’s paper
PDF hosted at the Radboud Repository of the Radboud University Nijmegen

9
da Silva Tavares, K.

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da Silva Tavares, K

Source – Another student’s paper
da Silva Tavares, K

A.,retrieved from:

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https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0037-1604178 Moscovitz, T., Tcherniakovsky, M., de Melo Pompei, L., & Fernandes, C.

Suspected Entry: 63% match

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https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0037-1604178 Moscovitz, T., Tcherniakovsky, M., de Melo Pompei, L., & Fernandes, C

Source – Another student’s paper
https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0030-1267860

E. (2017).

9
Differential diagnosis between Bartholin cyst and vulvar leiomyoma:

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Differential diagnosis between Bartholin cyst and vulvar leiomyoma

Source – Another student’s paper
Differential Diagnosis between Bartholin Cyst and Vulvar Leiomyoma

case report.

9
Revista Brasileira de Ginecologia e Obstetrícia/RBGO Gynecology and Obstetrics, 39(08), 433-435.

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Revista Brasileira de Ginecologia e Obstetrícia/RBGO Gynecology and Obstetrics, 39(08), 433-435

Source – Another student’s paper
Revista Brasileira de Ginecologia e Obstetrícia/RBGO Gynecology and Obstetrics, 39(08), 433-435

Retrieved from: https://repository.ubn.ru.nl/bitstream/handle/2066/173471/173471 #page=40

1
Rowley, J., Vander Hoorn, S., Korenromp, E., Low, N., Unemo, M., Abu-Raddad, L.

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Rowley, J., Vander Hoorn, S., Korenromp, E., Low, N., Unemo, M., Abu-Raddad, L

Source – Another student’s paper
Rowley, J., Vander Hoorn, S., Korenromp, E., Low, N., Unemo, M., Abu-Raddad, L

J.,. & Thwin, S. S. (2019).

1
Chlamydia, gonorrhoea, trichomoniasis and syphilis:

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Chlamydia, gonorrhoea, trichomoniasis and syphilis

Source – Another student’s paper
Chlamydia, gonorrhoea, trichomoniasis and syphilis

global prevalence and incidence estimates, 2016.

Suspected Entry: 100% match

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global prevalence and incidence estimates, 2016

Source – Another student’s paper
global prevalence and incidence estimates, 2016

Bulletin of the World Health Organization, 97(8), 548.

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Bulletin of the World Health Organization, 97(8), 548

Source – Another student’s paper
Bulletin of the World Health Organization, 97(8), 548

Retrieved from;

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https://www.who.int/bulletin/volumes/97/8/18-228486

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https://www.who.int/bulletin/volumes/97/8/18-228486

Source – Another student’s paper
https://www.who.int/bulletin/volumes/97/8/18-228486

Wald, A. (2018). Sexual practices and oral and genital herpes simplex virus shedding patterns among a cohort with laboratory documented first episode genital HSV-1. In Dublin:

12
The International Union against Sexually Transmitted Infections (IUSTI) World & European Congress.

Suspected Entry: 72% match

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The International Union against Sexually Transmitted Infections (IUSTI) World & European Congress

Source – Another student’s paper
The International Union against Sexually Transmitted Infections (IUSTI) was founded in 1923

: Retrieved from: https://safe-sex.co.il/wp-content/uploads/2018/Pro-Info/Sexual%20practices%20and%20oral%20and%20genital%20herpes%20simplex%20virus%20shedding%20patterns%20among%20a%20cohort%20with%20laboratory%20documented%20first%20episode%20genital%20HSV