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:
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.

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, negMcBurney
• Diagnostics: HSV specimen obtained
Assessment:
• Chancre
PLAN: This section is not required for the assignments in this course (NURS 6512) but
will be required for future courses.

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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.

Learning Resources

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 7, “Mental Status”

This chapter revolves around the mental status evaluation of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms.

• ·Chapter 23, “Neurologic System”

The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings.
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 4, “Affective Changes”
This chapter outlines how to identify the potential cause of affective changes in a patient. The authors provide a suggested approach to the evaluation of this type of change, and they include specific tools that can be used as part of the diagnosis.

Chapter 9, “Confusion in Older Adults”
This chapter focuses on causes of confusion in older adults, with an emphasis on dementia. The authors include suggested questions for taking a focused history as well as what to look for in a physical examination.

Chapter 13, “Dizziness”
Dizziness can be a symptom of many underlying conditions. This chapter outlines the questions to ask a patient in taking a focused history and different tests to use in a physical examination.

Chapter 19, “Headache”
The focus of this chapter is the identification of the causes of headaches. The first step is to ensure that the headache is not a life-threatening condition. The authors give suggestions for taking a thorough history and performing a physical exam.

Chapter 31, “Sleep Problems”
In this chapter, the authors highlight the main causes of sleep problems. They also provide possible questions to use in taking the patient’s history, things to look for when performing a physical exam, and possible laboratory and diagnostic studies that might be useful in making the diagnosis.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
• Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”) (Previously read in Weeks 1, 2, 3, and 5)
Note: Download the Physical Examination Objective Data Checklist to use as you complete the Comprehensive (Head-to-Toe) Physical Assessment assignment.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical examination objective data checklist. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance Center.

Note: Download and review the Student Checklists and Key Points to use during your practice neurological examination.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Mental status: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Kim, H., Lee, S., Ku, B. D., Ham, S. G., & Park, W. (2019). Associated factors for cognitive impairment in the rural highly elderly. Brain and Behavior, 9(5), e01203. https://doi.org/10.1002/brb3.1203

Lee, K., Puga, F., Pickering, C. E., Masoud, S. S., & White, C. L. (2019). Transitioning into the caregiver role following a diagnosis of Alzheimer’s disease or related dementia: A scoping review. International Journal of Nursing Studies, 96, 119–131. https://doi.org/10.1016/j.ijnurstu.2019.02.007

O’Caoimh, R., & Molloy, D. W. (2019). Comparing the diagnostic accuracy of two cognitive screening instruments in different dementia subtypes and clinical depression. Diagnostics, 9(3), 93. https://doi.org/10.3390/diagnostics9030093

Rubric Detail

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Name: NURS_6512_Week_9_Assignment1_Rubric

• Grid View
• List View
Excellent Good Fair Poor
Using the Episodic/Focused SOAP Template:
· Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned.

· Provide evidence from the literature to support diagnostic tests that would be appropriate for your case. 45 (45%) – 50 (50%)
The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study. 39 (39%) – 44 (44%)
The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study. 33 (33%) – 38 (38%)
The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected. 0 (0%) – 32 (32%)
The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
· List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. 30 (30%) – 35 (35%)
The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study and provides a thorough, accurate, and detailed justification for each of the five conditions selected. 24 (24%) – 29 (29%)
The response lists four to five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected. 18 (18%) – 23 (23%)
The response lists three to four possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or some inaccuracy in the conditions and/or justification for each. 0 (0%) – 17 (17%)
The response lists three or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic. 0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors. 4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors. 3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors. 0 (0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. 5 (5%) – 5 (5%)
Uses correct APA format with no errors. 4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors. 3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors. 0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors.
Total Points: 100
Name: NURS_6512_Week_9_Assignment1_Rubric

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Nurs 6512 week 10: Lab Assignment: Assessing the Genitalia and Rectum
Introduction
Gynecologic history and pelvic examination are vital during the physical evaluation of females. History taking is the first phase during the clinician-patient context as it is the basis of the physical examinations, diagnostic tests, and treatment plans. Both subjective and objective data are used to inform the list of potential diagnoses. Gynecologic history and pelvic examination require a private setting. This paper will discuss any additional information required in both subjective and objective portions and propose the possible differential diagnoses.
Additional Information Subjective Data
In the subjective part, it is important for the nurse to ask about the first time the patient noticed the bumps and whether the patient had received any treatment beforehand. Information about the recent history of fever could provide further information for the medical history. Additionally, it is necessary to ask if anyone in the household has scabies or lice to determine if the patient contracted the skin infection from someone in the family. It is also important to ask the characteristic of the lesions, for example, if the lesions are ulcer or crust-like or if the lesions have spread to any other part of the body (McBain et al., 2017). It is also necessary to ask about the history of skin conditions and also enquire about her reproductive history, including the number of sexual partners and if she practices safe sex. This is because some sexually transmitted infections manifest as lesions on the genital area (McBain et al., 2017). Other data that needs to be collected is about the GU systems such as hematuria, presence or absence of abnormal discharge, pain during urination, or dysuria.

Additional Objective Data
The HEENT examination is essential to evaluate the throat for redness, drainage, enlarged tonsils, edema, or sores. This can help in informing the possibility of any systemic infection with HSV or other viral infection. The neck also needs to be examined and documented for any enlarged cervical nodes, jugular venous distension, or nodal tenderness (Chen & Liu, 2021). The data about chest exam should be documented particularly for any signs of enlarged axillary nodes, tenderness over the nipple, and nonlabored breathing. It is essential to examine the cervix in order to evaluate for any cervical tenderness and motion. Breasts also need to be examined for any lumps or abnormal discharge.
Tenderness (Chen & Liu, 2021). The vagina needs to be inspected to determine the presence of rugae to assist in establishing the level of estrogen. Vaginal discharge needs to be examined to examine for the color, odor, consistency, and normalcy in the appearance of the discharge. The cardiovascular assessment also needs to document any peripheral pulses. An abdominal examination also needs to be performed through percussion, palpation, inspection, and percussion, and the findings documented (Chen & Liu, 2021). Finally, the appearance of the abdominal skill needs to be documented.
Diagnostic Tests
The HSV specimen was obtained for viral culture. HSV lab testing can help to determine and diagnose genital herpes infection. Another useful test is the polymerase chain reaction (PCR). A PCR can help to detect herpes simplex and thus confirm the diagnosis of HSV (Schremser et al., 2020). The presence of large multinucleated cells is an indication of a herpes lesion. Serology tests like non-treponemal pallidum test need to be conducted to rule out the diagnosis of syphilis. A rapid nucleic acid amplification test needs to be done to confirm or rule out chlamydia or gonorrhea (Van Der et al., 2020). A pap smear need could also have been included in the assessment because it has been more than 3 years since the client had a pap smear. A pap smear can detect the presence of human papillomavirus (HPV) infection.
Differential Diagnosis
• Chancre (primary stage of syphilis)
• Chancroid
• Genital warts
• Herpes simplex virus
• Herpes zoster
Diagnosis
• Chancre
Reject or Accept the Diagnosis
The initial stages of syphilis present as a painless chancre (O’Byrne & MacPherson, 2019). The ulcer begins as a papule and slowly becomes an indurated, firm, and painless ulcer (Gunn & Klausner, 2019). The physical examination along with the health history indicates that the patient had a chancre. In females, chancre presents on the vaginal area, anus, or vulva and takes about one month to 3 months to present after infection (O’Byrne & MacPherson, 2019). The ulcer is normally painless and very infectious. The patient reported a firm, rough and painless bump over the genital area. She did not report any abnormal vaginal discharge. She reported having multiple sexual partners and being sexually active in the past year. Therefore, she is at an increased risk of contracting a sexually transmitted infection such as syphilis, which starts as a chancre (Arando et al., 2019). Additionally, the objective data indicated the presence of a small, firm, round, and painless ulcer on the external labia. Therefore, the diagnosis of chancre is accepted as it is supported by both objective and subjective data.

References
Arando, M., Fernandez-Naval, C., Mota-Foix, M., Martinez, D., Armengol, P., Barberá, M. J., … & Vall-Mayans, M. (2019). Early syphilis: risk factors and clinical manifestations focusing on HIV-positive patients. BMC infectious diseases, 19(1), 1-9.
Chen, S. L., & Liu, C. C. (2021). Development and evaluation of a physical examination and health assessment course. Nurse Education Today, 107, 105116.
Gunn, R. A., & Klausner, J. D. (2019). Enhancing the control of syphilis among men who have sex with men by focusing on acute infectious primary syphilis and core transmission groups. Sexually transmitted diseases, 46(10), 629.
McBain, L., Pullon, S., Garrett, S., & Hoare, K. (2017). Genital examination training: assessing the effectiveness of an integrated female and male teaching programme. BMC medical education, 16(1), 299. https://doi.org/10.1186/s12909-016-0822-y
O’Byrne, P., & MacPherson, P. (2019). Syphilis. BMJ (Clinical research ed.), 365, l4159. https://doi.org/10.1136/bmj.l4159
Schremser, V., Antoniewicz, L., Tschachler, E., & Geusau, A. (2020). Polymerase chain reaction for the diagnosis of herpesvirus infections in dermatology : Analysis of clinical data. Wiener klinische Wochenschrift, 132(1-2), 35–41. https://doi.org/10.1007/s00508-019-01585-w
Van Der Pol, B., Taylor, S. N., Mena, L., Lebed, J., McNeil, C. J., Crane, L., … & Gaydos, C. A. (2020). Evaluation of the performance of a point-of-care test for chlamydia and gonorrhea. JAMA network open, 3(5), e204819-e204819.