Rectal Genitalia Assessment 2
Rectal Genitalia Assessment 2
- 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. Rectal Genitalia Assessment 2
Week 10: Special Examinations—Breast, Genital, Prostate, and Rectal GENITALIA ASSESSMENT
By putting the patient at ease, nurses are more likely to glean quality, meaningful information that will help the patient get the best care possible. When someone feels safe, listened to, and cared about, exams often go more smoothly. This is especially true when dealing with issues concerning breasts, genitals, prostates, and rectums, which are subjects that many patients find difficult to talk about. As a result, it is important to gain a firm understanding of how to gain vital information and perform the necessary assessment techniques in as non-invasive a manner as possible. Rectal Genitalia Assessment 2
For this week, you explore how to assess problems with the breasts, genitalia, rectum, and prostate.
Learning Objectives- Rectal Genitalia Assessment 2
- 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. Rectal Genitalia Assessment 2
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. Rectal Genitalia Assessment 2
- 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
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future course
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. Rectal Genitalia Assessment 2
Assignment: Lab Assignment: 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. Rectal Genitalia Assessment 2
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. Rectal Genitalia Assessment 2
To Prepare for Rectal Genital Assessment
- 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. Rectal Genitalia Assessment 2
- 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 fivepossible conditions that may be considered in a differential diagnosis for the patient. Rectal Genitalia Assessment 2
The Lab Assignment for Rectal Genital Assessment
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. Rectal Genitalia Assessment 2
By Day 7 of Week 10
Submit your Assignment.
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Learning Resources for Rectal Genitalia Assessment 2
Required Readings (click to expand/reduce)
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.
- Chapter 17, “Breasts and Axillae”This chapter focuses on examining the breasts and axillae. The authors describe the examination procedures and the anatomy and physiology of breasts.
- Chapter 19, “Female Genitalia”In this chapter, the authors explain how to conduct an examination of female genitalia. The chapter also describes the form and function of female genitalia.
- Chapter 20, “Male Genitalia”
The authors explain the biology of the penis, testicles, epididymides, scrotum, prostate gland, and seminal vesicles. Additionally, the chapter explains how to perform an exam of these areas.
- Chapter 21, “Anus, Rectum, and Prostate”
This chapter focuses on performing an exam of the anus, rectum, and prostate. The authors also explain the anatomy and physiology of the anus, rectum, and prostate.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 5, “Amenorrhea”
Amenorrhea, or the absence of menstruation, is the focus of this chapter. The authors include key questions to ask patients when taking histories and explain what to look for in the physical exam.
Chapter 6, “Breast Lumps and Nipple Discharge”
This chapter focuses on the important topic of breast lumps and nipple discharge. Because breast cancer is the most common type of cancer in women, it is important to get an accurate diagnosis. Information in the chapter includes key questions to ask and what to look for in the physical exam.
Chapter 7, “Breast Pain”
Determining the cause of breast pain can be difficult. This chapter examines how to determine the likely cause of the pain through diagnostic tests, physical examination, and careful analysis of a patient’s health history.
Chapter 27, “Penile Discharge”
The focus of this chapter is on how to diagnose the causes of penile discharge. The authors include specific questions to ask when gathering a patient’s history to narrow down the likely diagnosis. They also give advice on performing a focused physical exam.
Chapter 36, “Vaginal Bleeding”
In this chapter, the causes of vaginal bleeding are explored. The authors focus on symptoms outside the regular menstrual cycle. The authors discuss key questions to ask the patient as well as specific physical examination procedures and laboratory studies that may be useful in reaching a diagnosis.
Chapter 37, “Vaginal Discharge and Itching”
This chapter examines the process of identifying causes of vaginal discharge and itching. The authors include questions on the characteristics of the discharge, the possibility of the issues being the result of a sexually transmitted infection, and how often the discharge occurs. A chart highlights potential diagnoses based on patient history, physical findings, and diagnostic studies.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
- Chapter 3, “SOAP Notes” (Previously read in Week 8)
Cucci, E., Santoro, A., DiGesu, C., DiCerce, R., & Sallustio, G. (2015). Sclerosing adenosis of the breast: Report of two cases and review of the literature. Polish Journal of Radiology, 80, 122–127. doi:10.12659/PJR.892706. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4356184/
Sabbagh , C., Mauvis, F., Vecten, A., Ainseba, N., Cosse, C., Diouf, M., & Regimbeau, J. M. (2014). What is the best position for analyzing the lower and middle rectum and sphincter function in a digital rectal examination? A randomized, controlled study in men. Digestive and Liver Disease, 46(12), 1082–1085. doi:10.1016/j.dld.2014.08.045
Westhoff , C. L., Jones, H. E., & Guiahi, M. (2011). Do new guidelines and technology make the routine pelvic examination obsolete? Journal of Women’s Health, 20(1), 5–10.
This article describes the benefits of new technology and guidelines for pelvic exams. The authors also detail which guidelines and technology may become obsolete.
Centers for Disease Control and Prevention. (2019). Sexually transmitted diseases (STDs). Retrieved from http://www.cdc.gov/std/#
This section of the CDC website provides a range of information on sexually transmitted diseases (STDs). The website includes reports on STDs, related projects and initiatives, treatment information, and program tools.
Document: Final Exam Review (Word document)
Optional Resource for Rectal Genitalia Assessment 2
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
- Chapter 8, “The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts” (Section 2, “The Breasts,” pp. 434–444)Section 2 of this chapter focuses on the anatomy and physiology of breasts. The section provides descriptions of breast examinations and common breast conditions.
- Chapter 11, “The Female Genitalia and Reproductive System” (pp. 541–562)In this chapter, the authors provide an overview of the female reproductive system. The authors also describe symptoms of disorders in the reproductive system.
- Chapter 12, “The Male Genitalia and Reproductive System” (pp. 563–584)The authors of this chapter detail the anatomy of the male reproductive system. Additionally, the authors describe how to conduct an exam of the male reproductive system.
- Review of Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid” (pp. 445–527)
Required Media (click to expand/reduce)
Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 16 and 18–20 that relate to special examinations, including breast, genital, prostate, and rectal. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/