Assessing the Genitalia and Rectum Essay – Nursing 6512 – Week 10 Assignment

Assessing the Genitalia and Rectum Essay – Nursing 6512 – Week 10 Assignment

Introduction

Nurse practitioners will be faced with a wide range of cases that require a reserve of learning and mastery. Evaluating the genitalia and influencing a clinical conclusion when a patient presents with ambiguous subjective data can be difficult. Practitioners must be stellar with correspondence and evaluation aptitudes that will give the objective information needed to determine the appropriate diagnosis. This paper will dismember the subjective and the objective information introduced and recommend extra data that should be incorporated into this area of the SOAP note, as proved by references of current insightful literature. Assessing the Genitalia and Rectum Essay – Nursing 6512 – Week 10 Assignment. Also, current proof from literature will be displayed, analytic tests that would be imperative to assess, as well as subjective information from the patient will be recorded with references to either bolster or disprove this evaluation. As medical professionals, analytic tests must be upheld with clinical support about why it is relevant to the right diagnosis. At last, I will distinguish three conceivable conclusions to consider and put forth my defense for accepting or dismissing every finding, including the present diagnosis of choice.

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Analysis of Subjective Data

In this segment I will investigate the subjective information for this situation. The subjective information is as follows:

Chief Complaint (CC): “I have bumps on my bottom that I need to have looked at.”

History of Present Illness (HPI): AB, a 21-year-old white female, undergraduate student reports to the facility with outer bumps on her genital area. She expresses the bumps are not painful and feel rough. She states she is sexually active and has had in excess of one sexual partner over the previous year. Her underlying sexual contact happened at age 18. She reports no unusual vaginal release. She is uncertain to what extent the bumps have been there yet seen them about seven days prior. Her last Pap smear exam was three years prior, and no dysplasia was discovered; the exam results were ordinary. She reports one sexually transmitted disease (chlamydia) around two years back. She finished the treatment for chlamydia as endorsed. Assessing the Genitalia and Rectum Essay – Nursing 6512 – Week 10 Assignment.

Past Medical History (PMH): Asthma

Medications: Symbicort 160.4.5mcg

Allergies: NKA

Family History: Denies any history of breast/cervical cancer. Father has a history of HTN, and GERD.

Social History: Denies any tobacco or illicit drug use. She occasionally uses alcohol, she is married with 3 children (2 boys and 1 girl).

The subjective information displayed gives a clinical photo of the patient’s history. In the subjective part, a broad family history and patient history is important to decide a proper conclusion. (Raleigh, and Allan, 2017). At first, it is imperative to inquire as to whether she is up to date on her vaccinations and has ever had screening for Pap smears that were positive.  “Re-exposure inoculation is a standout amongst the best techniques for counteracting transmission of human papillomavirus (HPV), HAV, and HBV (Workowski, and Bolan,2015).

Furthermore, knowing who the health care provider that she has seen for the gynecology visit would be essential to assemble. Since she has a broad sexual history it would likewise be important to solicit whether any of her sexual partners were positive for STD’s and in the event that she has ever been tested for other STD’s. She expressed she was sure she had chlamydia however, data on STD treatment and screening is indispensable. Asking the patient when she last had sex and their identity would be critical on the off chance that the partner should be screened too. Exact risk evaluation and pre-exposure immunization of people in danger for antibody preventable STDs and also advising of sex accomplices of people tainted are fundamental. (Workowski, and Bolan, 2015).

Analysis of Objective Data

In this segment I will investigate the subjective information for this situation. The objective information is as follows:

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 with a healed episiotomy scar present. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia Assessing the Genitalia and Rectum Essay – Nursing 6512 – Week 10 Assignment

Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, neg McBurney

Diagnostics: HSV specimen obtained.

The practitioner that played out this objective appraisal, completed a concise head to toe evaluation with a concentrated evaluation on the genital region. In any case, there are fundamental frameworks that are missing, for example, neurological and mental. This patient is a 21-year-old female and could conceivably show anxiety about this examination which could hinder her psychological status.

Likewise, playing out a head to toe skin evaluation and surveying the mucosa in her mouth would be fundamental. Completing a concentrated skin evaluation on the genital area is proper yet because of her broad sexual history. Additionally, body appraisal is justified as more ulcers could be found. “Essential aversion of STDs incorporates playing out an evaluation of social risks and additionally biologic hazard” (Workowski & Bolan, 2015).

What’s more, it is important to obtain a pregnancy test to guarantee that treatment would be proper if from an infectious reason. HSV sample is suitable however advance STD testing would be fitting.

Support/Refuse Assessment

In this part, I will bolster the evaluation information as suitable for diagnosing a chancre. Because of the area of the ulcers in the genitalia and the patient’s subjective manifestation of the chancre being painless, I would bolster the analysis of chancre. In any case, I invalidate the objective portion of this contextual investigation as a result of the information being absent as talked about earlier and because of the way that the diagnostics are insignificant. Since there are no outcomes from HSV testing or other demonstrative testing demonstrating an infectious source, it is suitable to determine the patient to have chancre.  “Non-infectious genital ulcers can be overseen by the health care provider with pain control and consolation” (DeLellis & Yen, 2017).

Diagnostic Tests

In this segment I will recommend fitting demonstrative tests and how each could be utilized to analyze this patient, as per the present literature.

In the patient’s objective information, HSV testing is fitting. This is fundamental to arrange when sores are available. HSV testing has a higher sensitivity level than a viral culture. As indicated by an investigation, the most elevated yield if vesicles can be unroofed and the base of a ulcer can be scratched with a Dacron swab, it will give the most exact information for diagnosing. Moreover, a type-specific serologic IgG measure would demonstrate current disease with HSV and STD screening. . On the off chance that this test would be negative, disease is still presumed, this test can be re-done in 6-12 weeks. The patient’s vital signs don’t recommend a fever but completing a CBC would be proper to surely preclude a contamination (Shah & Kantharia, 2017). Assessing the Genitalia and Rectum Essay – Nursing 6512 – Week 10 Assignment.

Differential Diagnoses

In this segment I will list somewhere around 3 conceivable findings, with contentions for accepting or dismissing each, as upheld by the present proficient literature.

1. Chancre

This differential finding is satisfactory in this patient’s case because of the way that the patient has bumps on her outer labia. Likewise, chancres are common in ladies who have numerous sexual partners. Portrayal of initial periods of syphilis incorporate the presence of a solitary chancre denotes the essential (first) phase of syphilis indications, yet there might be various wounds as this patient has in her labia (Mochtar, et al, 2017). The trademark presentation of a chancre is typically firm, round, and painless which is the thing that the patient reports subjectively. These chancres last about three to six week and heal in any case if the patient gets treatment. Be that as it may, if not treated, this can deteriorate into (Sexually Transmitted Diseases (STDs). Analytic testing for syphilis incorporate the accompanying: positive nontreponemal test (e.g., fast plasma reagin/Venereal Disease Research Laboratories titer, darkfield microscopy result) or a positive treponemal serology test. RPR test would demonstrate positive and would be affirmed by serology for Treponema pallidum (Mochtar, et al, 2017).

2. Chancroid

This differential finding is dismissed because of the way that chancroids present as a solitary profound ulcer and the patient expresses that it is excruciating. Besides, the patient would likewise grumble about a burning sensation on the ulceration which isn’t expressed above (Mochtar, et al, 2017). The patient’s current subject manifestations for the situation ponder states that the bumps are painless and feel rough. This information alone would reject the determination of chancroid. Assessing the Genitalia and Rectum Essay – Nursing 6512 – Week 10 Assignment. Furthermore, if a PCR was performed for diagnostics it would demonstrate Haemophilus ducreyi on a culture (Mochtar, et al, 2017).

3. Herpes Simplex Virus

This differential afinding would be rejected on the grounds that as per the contextual investigation the patient does not have tingling, burning without sores and basic manifestations seen of herpes labialis incorporate tingling and burning and afterward successive idevelopment of vesicular then ulcerative injuries that are in the oropharynx and perioral mucosa. There is no proof recommending that the patient has vesicular sores in her oropharynx or mucosa and the patient does not have subjective indications of ingling and burning (Mochtar, et al, 2017).

In conclusion, recognizable proof of 3 differential findings and the acknowledgment of the analysis of chancre was talked about in this paper. Intensive examination of subjective and objective information from this contextual analysis was talked about alongside suitable indicative tests. As health care providers, the way to proper diagnoses is stellar patient evaluation and emotional information accumulated from the past medicinal history.

References

DeLellis, D., & Yen, G. (2017). A Case of Non-infectious Genital Ulceration. Proceedings of UCLA Healthcare, 21.

Kim, D. W., Kwak, H. B., Yun, S. K., Kim, H. U., & Park, J. (2016). P282: Mutiple oral and genital syphilic chancre. 프로그램북 (구 초록집), 68(1), 400-401.

Mochtar, M., Murasmita, A., Irawanto, M. E., & Elistasari, E. Y. (2017). Genital Ulcers in Women with HIV Proposed Revision on Management Algoritm. American Journal of Life Sciences, 5(3), 93-96.

Raleigh, M., & Allan, H. (2017). A qualitative study of advanced nurse practitioners’ use of physical assessment skills in the community: shifting skills across professional boundaries. Journal Of Clinical Nursing, 26(13-14), 2025-2035. Assessing the Genitalia and Rectum Essay – Nursing 6512 – Week 10 Assignment

Sexually Transmitted Diseases (STDs). (2017, February 13). Retrieved from https://www.cdc.gov/std/syphilis/stdfact-syphilis-detailed.htm

Shah , A.N., & Kantharia, B.K. (2017, January 23). Acute atrial fibrillation.San Mateo, CA :
Epocrates, Inc..Retrieved  August, 2, 2017 from www.epocrates.com

Workowski, K. A., & Bolan, G. A. (2015). Sexually transmitted diseases treatment guidelines, 2015. MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports, 64(RR-03), 1. Assessing the Genitalia and Rectum Essay – Nursing 6512 – Week 10 Assignment