NURS 6512 Advanced Health Assessment and Clinical Diagnosis Discussion

NURS 6512 Advanced Health Assessment and Clinical Diagnosis Discussion

NURS 6512 Advanced Health Assessment and Clinical Diagnosis Discussion

Week 10: Special Examinations—Breast, Genital, Prostate, and Rectal

One critical element of any physical exam is the ability of the examiner to put the patient at ease. 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.

For this week, you explore how to assess problems with the breasts, genitalia, rectum, and prostate.

Learning Objectives

Students will:

• 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

Learning Resources

Required Readings

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

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 

Special Examinations – Breast, Genital, Prostate, and Rectal – Week 10 (14m)

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/

Special Examinations—Breast, Genital, Prostate, and Rectal Example Paper

Assessment of genital, like other systems, can be systematically done through a SOAP note. The SOAP note presented described the history and physical examination (H & P) finding of the patient, AB, with a disease condition of the genitourinary system. This assignment will, therefore, evaluate and analyses the provided SOAP note and provide additional information that may be missing.

Evaluation of the Subjective Data

The subjective data presented is brief and precise; however, there some additional components that would complement the H&P for a more accurate diagnosis. The chief complaint (CC) is recorded in the patient’s own words as should be (Ball et al., 2019). The History of Presenting Illness (HPI) is elaborate but is missing some important positives and negatives. The history of diabetes mellitus should be added to rule it out. Diabetes, regardless of age and gender, can present with genitourinary symptoms such as changes in urinary color and frequency. The presence of infections can be associated with immunosuppression in diabetes mellitus. Additional information on the genitourinary system including the absence of dysuria, retention, lower abdominal pain, and frequency would be useful in delineating urinary from reproductive etiology in AB’s situation. Urinary tract infections may present similarly to the infections of the reproductive system in some cases. Moreover, ascending infections may arise in both cases, urinary and genital infections.

AB is also asthmatic and is on medication, Symbicort. This medication is a steroid that can cause suppression of the immune system. The subjective data should, therefore, provide the duration for which AB has used this medication and the frequency of usage to rule its association with the infection. Because of her gender, it would be prudent to ask about the last menstrual period (LMP) and the use of contraceptives. Contraception use has a role in the development of infection of the genitourinary tract through alterations in microflora among other mechanisms (Price et al., 2020). Therefore, the reproductive history provided ought to be more comprehensive and specific. The sexual history doesn’t describe the type of sexual intercourse she engages in and the use of protection.  This would be important in investigating other organs such as the upper gastrointestinal system (GIT), and anorectal regions for sexually transmitted infections

Evaluation of the Objective Data

The objective data provided is precise but missing vital routine assessments as well. The general assessment of the patient provides the overall picture of the impact of the disease on the patient. The inclusion of overall patient psychological impact as part of the general assessment would influence the management of the patient, health promotion, and maintenance. Physical examination of the female genitalia also includes the assessment of the anus and rectum. However, this is not the case with the provide SOAP note’s objective data. Due to their proximity, anorectal diseases may also affect the genitourinary system. Examination of the pertinent lymph nodes for enlargement would also be relevant to AB’s SOAP note. Infectious, as well as neoplastic conditions, can present with lymph node swelling (Agharbi, 2019). Further description of the enlarged nodes, if any, would be necessary as well.

Other tests that would have been ordered include complete blood counts, random blood sugar, and Giemsa staining of the swab sample, urinary dipstick, and microscopy. Random blood sugar would rule out the possibility of diabetes mellitus while complete blood counts would be used to infer the type of infections if any is present. The provided assessment, chancre, is appropriate for the patient’s condition. Chancre, usually caused by treponema pallidum causes painless lesions in the genital area (Katz et al., 2019). The history of multiple sexual partners predisposed her to develop this condition. Urinary dipstick analysis would be used to rule out the possibility of an underlying or concurrent urinary tract infection.

Differential Diagnoses

AB presented with painless, round small ulcers on her external labia. The possible differential diagnoses include herpes simplex, herpes zoster infection, condyloma acuminata, lymphogranuloma venereum, urinary tract infection, genital warts, granuloma inguinale (Chandrasekar et al., 2017), and chancroid. The lesion was ‘single’ and painless and this makes chancroid the least likely differential diagnosis in her. Moreover, chancroid is epidemiologically most common in low- and middle-income countries. The presence of urinary tract infection cannot be ignored in the evaluation of her because the subjective data was insufficient regarding the genitourinary symptoms that would direct further investigations. The similarity in presentations of urinary tract infections (UTIs) and sexually transmitted infections (STIs) often lead to underdiagnosis or misdiagnosis of urinary tract infections (Behzadi et al., 2019). Therefore, further workups are needed to confirm the etiology of her genital lesion.

The patient reported that her last Pap smear test was three years ago. While Human Papilloma Virus requires incubation of up to nine months for symptoms to appear (Ghadishah et al., 2018), it is possible that AB might have contracted this etiological agent after the last negative Pap smear tests. Granuloma inguinale (Donovanosis) is a possible diagnosis in this patient. However, this disease is less common in temperate regions than the tropical and subtropical regions where annual incidences are high (Satter & Elston, 2017). The presence of painless ulcers makes donovanosis unlikely as well. Distinguishing the ulcers from herpes zoster and herpes simplex n this patient would require further virological serology testing. Their likelihood of appearing in this patient cannot be excluded due to the insufficient history.

Conclusion

This week’s case study, provided in a SOAP note format, presented a genitourinary disease in a young female patient, AB. The additional information in the subjective and objective data would majorly describe further the sexual history and genitourinary systematic review to direct further the specific investigations. Most likely differentia diagnoses include UTIs, genital warts, herpetic ulcers, and donovanosis among other diagnoses described.

References

Agharbi, F.-Z. (2019). Chancre mou. The Pan African Medical Journal, 33. https://doi.org/10.11604/pamj.2019.33.185.16187

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.). Mosby.

Behzadi, P., Behzadi, E., & Pawlak-Adamska, E. A. (2019). Urinary tract infections (UTIs) or genital tract infections (GTIs)? It’s the diagnostics that count. GMS Hygiene and Infection Control, 14, Doc14. https://doi.org/10.3205/dgkh000320

Chandrasekar, P. H., Talavera, F., Brusch, J. L., & Bronze, M. S. (2017). Syphilis Differential Diagnoses. Medscape.Com. https://emedicine.medscape.com/article/229461-differential#1

Ghadishah, D., Talavera, F., & James, W. D. (2018). Genital Warts; Medscape.Com. https://emedicine.medscape.com/article/763014-overview#a4

Katz, A. R., Johnson, D. W., Komeya, A. Y., Tomas, J. E., Namiki, T. S., & Kobayashi, K. (2019). Dermatologically challenging syphilis presentation. International Journal of STD & AIDS, 30(7), 707–709. https://doi.org/10.1177/0956462418817636

Magill, A. J., Strickland, G. T., Maguire, J. H., Ryan, E. T., & Solomon, T. (2020). Hunter’s tropical medicine and emerging infectious disease: Expert consult – online and print (9th ed.). Saunders.

Price, T. K., Wolff, B., Halverson, T., Limeira, R., Brubaker, L., Dong, Q., Mueller, E. R., & Wolfe, A. J. (2020). Temporal dynamics of the adult female lower urinary tract Microbiota. MBio, 11(2). https://doi.org/10.1128/mbio.00475-20

Satter, E. K., & Elston, D. M. (2017). Granuloma Inguinale (Donovanosis). Medscape.Com. https://emedicine.medscape.com/article/1052617-overview#a4

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.

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.
• 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.

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.

By Day 7 of Week 10

Submit your Assignment.

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NURS 6512 Advanced Health Assessment and Clinical Diagnosis Discussion Rubric Detail