ASSESSING THE GENITALIA AND RECTUM

GENITALIA ASSESSMENT

Genitourinary Assessment

CC: Increased frequency and pain with urination

HPI:

T.S. is a 32-year-old woman who reports that for the past two days, she has dysuria, frequency, and urgency. Has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months.

Medical History:

None

Surgical History:

· Tonsillectomy in 2001

· Appendectomy in 2020

Review of Systems:

· General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.

· Abdominal: Denies nausea and vomiting. No appetite

Objective 

VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.

Pelvic Exam:

· mild tenderness to palpation in the suprapubic area

· bimanual pelvic examination reveals a normal-sized uterus and adnexae

· no adnexal tenderness.

· No vaginal discharge is noted.

· The cervix appears normal.

· Diagnostics: Urinalysis, STI testing, Papsmear

Assessment:

· UTI

· STI

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

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.

RUBRIC FOR GRADING

With regard to the SOAP note case study provided and 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. = The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation.

Analyze the objective portion of the note. List additional information that should be included in the documentation. = The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation.

Is the assessment supported by the subjective and objective information? Why or why not? = The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.

What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis? = The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be use

d to make a diagnosis.

 Would you reject or accept the current diagnosis? Why or why not?·   Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature. The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature.

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.= 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.

This criterion is linked to a Learning OutcomeWritten Expression and Formatting - English writing standards: Correct grammar, mechanics, and proper punctuation. = Uses correct grammar, spelling, and punctuation with no errors.

This criterion is linked to a Learning OutcomeWritten 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. Uses correct APA format with no errors.