Pages: 4 pages ( 1100 words, Double spaced)
Instructions attached
NURSE NURSE
Pages: 4 pages ( 1100 words, Double spaced)
Academic level: Undergrad. (yrs 3-4)
Subject or discipline: Nursing
Title: Writer’s choice
Number of sources: 4
Paper instructions:
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.
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, negMcBurney
• Diagnostics: HSV specimen obtained
Assessment:
• Chancre
Example of the paper is very long, I only need about 4 pages
Assessment of the Genitalia and Rectum
Student Name
University
Course
Instructor
Date of Submission
Assessing the Genitalia and Rectum
Overview
Regularly, care providers are faced with various challenges that require knowledge and skills to address
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As indicated by McBain, Pullon, Garrett, and Hoare (2016), it is not easy to evaluate the genitalia and make use of the evaluation in making and influencing a medical conclusion. Genitalia assessment is challenging at the point when a client visits a care facility giving unclear subjective information. Care providers should be equipped with adequate assessment and communications capabilities to enable them to gather objective data which is critical it the determination of the correct diagnosis (McBain, Pullon, Garrett & Hoare, 2016). This assignment aims to disintegrate the subjective and objective data that is provided and recommending additional information that ought to be included in the SOAP note. The process ought to match the present-day intuitive literature. Besides, the current literature-based proof will be availed. Analytic evaluation that is critical in the evaluation process will be assessed, and the patient’s subjective data will be documented. This is aimed at supporting or disproving the evaluation. The care provider will uphold an analytical test by making use of pertinent health support regarding the importance of making an appropriate diagnosis. Finally, the paper will distinguish practical conclusions to take into consideration and justify each outcome, including the current diagnosis.
Analysis of subjective data
In this part, I will assess the subjective data regarding the subject situation. Subjective information incorporates the data that is availed by the client regarding his or her symptoms. Under normal circumstances, it incorporates perceptions, feelings, and concerns. Subjective information is critical since it provides the care provider with the patient’s background concerning the purpose of the presentation. The therapists can understand the whole matter by giving ear to the patient (Colby et al., 2017). When the client is giving subjective information, the therapist is expected to take notes to have a better understanding of the patient’s problem. The notes enhance the illustration of the patient’s account. Patients have a better understanding of them thus listening giving ear to their problems will potentially facilitate a better outcome. Listening enhances the therapist to promote for the patients’ needs appropriately. The client’s objective data is as indicated below:
. CC: “There are bumps in my bottom which is would like to be assessed”
• HPI: MD is aged 21, and she is a BB college student. She presents at the care facility complaining of external bumps around her genital region. As per her report, the bumps are not painful but they are firm. She expresses that she is active sexually and that she had been involved in numerous sexual relationships over the past 12 months. She first exposed herself to sexual contact when she was 19. The client refutes an unusual vaginal discharge. The patient is uncertain concerning the period she has been experiencing the bumps. However, she expresses that she became aware of them almost a week ago. She lastly was subjected to a Pap smear test three years ago, and the outcome indicated no dysplasia. The client reported chlamydia as the only STI she has ever suffered, almost 3 years go. She complied with and accomplished chlamydia treatment as required
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• PMH: Asthma
• Medications: 160/4.5mcg Symbicort
• Allergies: NKDA
• FH: the absence of hx of cancer of the cervix or breast cancer. Dad History HTN, history of the mom GERD, HTN.
• Social: refutes smoking tobacco. In marriage, a mother of three, occasional EtOH
The indicated subjective information is critical in giving an impression of the patient’s history. The subjective information concerning the patient’s parents are important for making a relevant decision (DeLellis & Yen, 2017). To begin with, it is significant to make an inquiry from the client whether she adheres to the immunization; whether she is up to date on her vaccination. Besides, it is critical to understand whether the Pap smear test was positive. As indicated by Workowski and Bolan (2015), re-exposure inoculation is the right criterion for curbing the spread of HAV, HPV, and HBV.
Besides, it is necessary to know the care provider who tended to the patient’s gynecological needs. Based on the subjective data above, it is indisputable that the client has an extensive sexual background, and she has revealed having been engaged in numerous sexual relationships with different partners in the past 12 months. At the moment, the care provider should establish whether the patient’s sexual partners had suffered any STI and whether the patient has ever been screened for STIs. The client expressed that she previously was diagnosed with chlamydia, though information concerning how the STD was treated is important. The care provider should be aware of the last period when the client had sexual intercourse because it would be important in the determination of whether the client’s partner ought to be subjected to testing. According to Workowski and Bolan (2015), the precise pre-exposure and assessment of risks is critical for the establishment of correct diagnosis.
The documentation of the patient’s information ought to integrate the Review of Systems after assessing the patient’s subjective data. Likewise, it is significant to take into consideration the history that should be obtained from the patient on the off chance that they present with symptoms different from those associated with syphilis particularly in case there is no other etiology established. Some of the symptoms incorporate manifestations of meningovascular disorders such as cerebrovascular accidents, chronic headache, meningitis, impairment of the cranial neuron and aortic insufficiency.
Analysis of Objective Data
This part of the assignment will assess the objective data for the case provided. Objective information denotes measurable variables or data that can be obtained based on key manifestations, or physical assessment, laboratory and diagnostic evaluation. Objective information cannot be disputed (Colby et al., 2017). The client’s objective information is illustrated below;
• VS: Temperature 98.6; Blood Pressure 120/86; Respiratory rate16; P 92; Height 5’10”; Weight 169lbs
• Heart: RRR, absence of murmurs
• Lungs: Chest wall symmetrical, CTA.
• Genital: The pattern of the distribution normal, absence of swelling and masses. No flaw detected in her urethral flaw, absence of discharge. Perineum flawless, presence of rugae in her pink and moist mucosa, except for small, stiff, painless, and painless present on the external labia.
• Abd: Tender, normal bowel sounds, no rebound, McBurney, and murphy’s
• Diagnostics: HSV culture acquired.
The care provider who conducted the objective assessment performed extensive assessment but gave much emphasis on the genitalia. However, there are some key missing data, for example, neurological and psychological data. The client is aged 21, and her assessment tests indicated anxiety which is a hindrance to mental stability.
Besides, the care provider should perform head to toe evaluation of the skin and concentrate on the genitalia based on complex history (Workowski & Bolan, 2015). Since ulcers can be identified, the care provider ought to carry out body assessment. To effectively avert STIs, the care provider is expected to assess both social and bioethics risks. Besides, it is important to subject the client to a pregnancy test to guarantee treatment (Ball et al., 2015).
The subjective and objective data concerning the actual assessment (Chancre)
The objective and subjective information fully support the examination, especially concerning the sample of HSV that was obtained to eliminate genital HSV. The patient, in this case, is manifesting typical symptoms that are in line with those associated with primary syphilis. Such symptoms incorporate painless ulcers of the genitalia. In this case, pain is an important element that usually varies especially at the point when Chancroid is a differential diagnostic and there is a necessity to eliminate it. When the therapist considers syphilis assessment of the next sexually active patient, s/he should establish is among the demographic population characteristic of a high prevalence of syphilis.
Are diagnostics appropriate for this case and how the results are used in making a diagnosis?
The reliance of only physical assessment and history of the patient in the diagnosis of Chancre (primary syphilis) may not be effective since some variables such as pain, numerous ulcerations, and inguinal lymphadenitis are not certain symptoms for diagnosing any disorder. Nevertheless, other results are characteristic of certain disorders. The care provider should make use of diagnostic tests to support extensive discussion regarding how to assess patients having genitalia ulcers. Irrespective of the absence of symptoms, it is critical for therapists to perform Chancroid diagnostic tests. Serologic testing is the most commonly used diagnostic testing concerning primary syphilis.
The basis for the rejection or acceptance of the current diagnosis (chancroid)
Because genital HSV was eliminated and the HSV sample was obtained, Chancre (primary syphilis) can be considered. A chancre is a chronic abrasion for primary syphilis. Normally, the disorder manifests itself about 4 weeks after an individual has been infected but disappears roughly 2 months later for untreated individuals. The abrasion begins as an erythematous papule at the inoculation point which develops to become painless ulcerations (Hamill, Seppings, Kit & Antao, 2018). Many chancres can develop at the same time, especially in individuals living with HIV/AIDS. A serous discharge is secreted from the abrasions characterized by spirochetes. Males normally experience the abrasions around the anus and the rectum. In ladies, they experience the abrasions around the perineum, vulva, and cervix. Small lesions are also likely to be manifested on the skin, eyelids, lips, conjunctiva and the lining of the mouth (Hamill, Seppings, Kit & Antao, 2018). Chancre (primary syphilis) is observed as solitary painless ulceration that is not associated with pus or crust. On palpation, their bases feel stiff. The ulceration may or may not be associated with regional lymphadenopathy. The clinical setting may be suggestive of Chancroid. Nevertheless, the ultimate diagnosis is dependent on syphilis’ laboratory tests.
For the patient, in this case, the correct diagnosis id Chancroid based on the fact that the patient’s external labia are infested with bumps. Also, chancres are usually chronic in females who engage in sexual intercourse with more than one partner. The initial phases of the development of syphilis incorporate the presence of chancre. Nonetheless, there is a possibility of this patient having numerous labia wounds (Yu & Zheng, 2016). Normally, chancre is presented with a round, painless and stiff lesion that is the client reports subjectively. The chancre can be experienced for 3 to 6 weeks and heals in medically addressed (Mochtar, Murasmita, Irawanto & Elistasari, 2017). Nonetheless, on the off chance that the treatment is ineffective, it can advance to be an STD (Yu & Zheng, 2016). Syphilis can be assessed using analytic testing which incorporates positive treponemal and nontreponemal serology testing. Treponema pallidum serology can be helpful in the affirmation of the RPR test in case it indicates any positives (Mochtar, Murasmita, Irawanto & Elistasari, 2017).
Diagnostic Tests
This section will recommend suitable demonstrative tests, and the practicability of the test in examining the client in this case study, which ought to match the present-day literature.
Regarding the client’s objective data, an HSV test is necessary, which is helpful in case there is the presence of sores. HSV testing has a higher sensitivity in comparison to viral culture. Research has indicated that the key yields include vesicles that can be unroofed with ease, enhancing ulcer scratching through the Dacron swab (Hamill, Seppings, Kit & Antao, 2017). This provides the most accurate data that can help make a diagnosis. Besides, the use of a type-specific serologic IgG can help to demonstrate the current disorder though HSV and STD screening. The results of the test might be negative sometimes, an indication that the disorder can be assumed. The test can be repeated at some point between the 6th and the 12th treatment weeks. Regarding the key symptoms of the client, fever ought to be discounted, but it is significant to conduct CBC, which is significant in preventing contamination (Hamill, Seppings, Kit & Antao, 2017).
Differential diagnosis
Most genital ulcerations are caused by STIs. Nevertheless, other noninfectious etiologies ought to be considered on the off chance that STIs have been eliminated. In most parts of the world, the US included, genital ulcer disease is caused by syphilis and also herpes simplex virus. In some men who engage in homosexuality, there has been an observation of lymphogranuloma venereum outbreak. Additional pathogens sexually transmitted due to genital ulcers are less common in the US. Nevertheless, micro-organisms can be common in other global regions. Genital ulcers increase the vulnerability of the contraction of HIV. The care provider should establish why the genital ulcers developed in young individuals in a mission to identify the most appropriate methodology of treatment and lessen the probability of other individuals contracting the disorder. However, it is not easy to establish the etiology due to limitations that the present-day diagnostic modalities experience and the probability of people having more than one disorder. The following are the potential diagnoses:
(1). Epidermal cysts –They include keratin cysts and cysts of the epithelia. They appear small, and they are stiff and normally develop under the skin. They are less common and their development is gradual. In most cases, they are not associated with further symptoms and nearly they are not associated with cancer. Epidermoid cysts develop on the face, neck, genitals, and back (Devos et al., 2017). They vary in size ranging from a quarter an inch to two inches. They are small bumps and they vary in color and they are characterized by a smelly fluid. They are painless and the probability of being assumed is higher. The development of keratin is perceived as the trigger of the development of epidermoid cysts. Keratin denotes a natural protein in the skin cells. On the off chance that protein is stuck beneath the skin due to interruption of the skin hair follicles, cysts grow. They cyst development is a reaction to disturbance the skin is exposed to, HPV infection, exposure to the sun for a long period, and acne. People having acne or suffering from disorders of the skin are more vulnerable to epidermoid cysts (Devos et al., 2017). There is a necessity of the care provider to assess the bump at the skin nearby and also to gather an adequate medical history of the client for an effective diagnosis of epidermoid cysts. The therapist ought to be provided with data incorporating the span of the existence of the bump and whether the bump has evolved over the span. Some care providers diagnose epidermoid cysts through assessment. Nevertheless, they are expected to perform an ultrasound test or refer the client to a skin expert for further assessment (Devos et al., 2017). The diagnosis of epidermoid cysts can be clinically done. Inflamed lesions can be differentiated from furuncles and carbuncles by making use of nodule history which was initially not inflamed, color, the smelly fluid, surface opening and the sequence of their arrangement.
(2). Bartholin cyst- The similarity between Bartholin cyst and primary syphilis is that normally Bartholin cysts are painless and their diameter range between 1 to 3cm, just like Chancroid. Also, Bartholin cysts are unilateral and do not show manifestations (Silman et al., 2018). The identification of Bartholin cysts can occur during the assessment of the pelvis. The establishment of the cysts can also occur by the affected woman, just like in the case of the patient in this case. Big cysts are associated with uneasiness especially when the affected individual is seated, having sexual intercourse or ambulating (Silman et al., 2018). The cyst can disfigure the victims thought the cysts are asymptomatic. Normally, the cysts are painful and they cause swelling that can impair the ability of the patient to copulate and walk (Silman et al., 2018).
The evaluation of potential Bartholin cysts incorporates performing an assessment of the pelvis and acquiring of the client’s medical history. The fluid produced in the cysts can be tested in the lab in a mission to acquire methicillin-resistant Staphylococcus aureus. The assessment of this kind of cysts requires no imaging test. Besides, there is no need for blood screening on the off chance that the systemic disorder is not anticipated (Silman et al., 2018). Vulvar assessment is conducted and it involves physical examination in addition to palpation of the cyst. The procedure of the palpation of the Bartholin gland calls for holding of the upper section of the labium between a finger at the back of the introitus of the vagina and the placement of the thumb horizontal to the labium. The palpation of typical Bartholin is challenging especially for fat women. Bartholin lesions are unilateral. During assessment, the cysts are moist, tender, and fluctuating structure around the labia and vestibular areas. For large lesions, they are likely to extend to the upper parts of the labia. Also, on the off chance that the lesions occur adjacent to the surface, pus may ooze out via the epithelium of the skin.
(3). Lymphogranuloma venereum (LGV) – The disorder is rare in developed countries. It is the cause of proctitis in homosexual men more so the inhabitants of North America, Europe, and the UK. Lymphogranuloma venereum is genital ulceration that incorporates STDs such as Chancroid, HSV-2, and syphilis (Saxon, Hughes & Ison, 2016). The ailment is characterized by limited papules or ulcerations associated with extreme pain in the linual and femoral lymphadenopathy. The above can be the only presenting manifestations of a client. Individuals suffering from Lymphogranuloma venereum sometimes experience ulcers on the rectum apart from symptoms of proctocolitis especially in people who take part in anal sex. For such situations, the pain of the rectum, discharge, and bleeding are mistaken with numerous GI infections, for example, colitis. On the off chance that the disorder is not medically attended the external genitalia might grow excessively, be manifested by disfiguring lesions coupled with obstruction of the lymphatic system (Saxon, Hughes & Ison, 2016). The presence of LVG renders the chlamydia nucleic acid amplification test positive, even though the test is illegal for this reason in the US (Saxon, Hughes & Ison, 2016). LVG diagnosis can be facilitated through serologic tests. It is not easy to determine LVG because there are no specific symptoms associated with the disorder, the pathogen’s lab procedures need updating, and its serologic assessment is unclear (Saxon, Hughes & Ison, 2016). However, nucleic acid amplification testing is an alternative that can be conducted in labs. Individuals suffering from genital disorders can be tested through the identification of nucleic acid, abrasion swab, direct immunofluorescence, and abrasion swab (Saxon, Hughes & Ison, 2016). A correct diagnosis depends on the effective collection of the client’s sexual history.
(4). Chancroid- This is a rare disorder in the US and other well-developed countries. Nonetheless, its prevalence is not well documented since its precise diagnosis needs the identification of the causative micro-organism, yet a large percentage of research centers are not well equipped with the required gear to conduct an effective diagnosis. Besides, many care providers put little effort in diagnosing disorders of the genital ulcers that are caused by micro-organism apart from herpes simplex infection of Treponema pallidum. Chancroid diagnosis can be done using a particular culture. A couple of research centers have come up with certified PCR chancroid tests. According to (Fouere et al., 2018), chancroid’s incubation span is usually 4 to 10 days. H.ducleyi infection causes the development of erythematous papule which turns to be a pustule and later an ulcer. Victims of this disorder normally suffer a single ulcer, and the abrasions normally develop in the genital region and the degenerating lymph nodes
When evaluated, the diameter of a normal ulcer ranges between 1 and 2 cm, though it can vary. A large number of ulcers might be present especially in individuals diagnosed with HIV. Unlike chancroid ulcers, unlike ulcers causes a lot of pain and has an erythematous base characterized by delineated margins. When scratched, the ulcers normally produce a yellow fluid and blood. H. ducreyi pathogenesis indicates that the most vulnerable regions for chancroid are those that are exposed to friction during copulation. Among the females, vaginal introitus, perianal area, and the labia are exposed to the greatest risk. Some cases of chancroid go uncovered, especially in asymptomatic females having vaginal lesions (Fouere et al., 2018).
This outcome is refuted since chancroid is manifested as a single ulceration. Besides, patients experience pain, all of which are absent in this case (Fouere et al., 2018). The client complains of bumps that are stiff and does not cause pain. This data is a platform for the elimination of chancroid. Finally, on the off chance that the patient is exposed, the culture will indicate H. ducreyi.
(5). Genital Herpes Simplex Virus (HSV) –It develops as a result of having sex between a vulnerable person (without antibodies for this virus) and an individual having body fluid with a virus. Virus shedding takes place during primary infection, amid recurrences next to each other, and asymptomatic viral shedding stages. In between these stages, contact must include mucosa membranes and scratched skin (Looker et al., 2015). Next is the identification of HSV primary infection at the exposure stage. By now, viral casing, and the cell membrane of the skin except for mucosa membranes are attached. The HSV’s DNA is introduced into the nucleus. After toll-like receptors recognize the DNA of the HSV, activation of adaptive and innate body defense mechanism follows and there is a formation of interferon genes products (Looker et al., 2015). Viral management of host cell reactions and the consequent prevention of the defense framework are obtained by different exchanges between the body framework of defense and HSV virion protein contents (Looker et al, 2015). The average period of incubation following infection is 4 days (with chances of varying between 2-12 days). Other signs and side effects during these initial phases of infection include Systemic manifestations which entail high temperatures in the body, malaise, myalgias-67%, migraine, Local agony, and irritation-98%; Dysuria-63%; Tender lymphadenopathy-80%. Therefore, clinicians must find out differences between intense urinary retention and dysuria, which may develop during acute basic HSV infection. Dysuria may cause resistance to void because acidic urine passes on painful and open vesicles, although making use of Sitz baths may help control this complication (Looker et al., 2015).
This outcome is ruled out since this client is not experiencing manifestations of burning and tingling without the lesions. Herpes labialis manifestations include tingling and burning and effective growth of ulcerative injuries contained in the oropharynx and perioral mucosa (Looker et al., 2015). Given the above subjective data of this client, there are no signs of her having vesicular sores in either her oropharynx or mucosa. Also, this patient has not indicated subjective signs of angling and burning.
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