Genitourinary Assessment Analysis Assignment Paper
Week 10 Assignment- Genitourinary Assessment Analysis of T.S.
T.S., a 32-year-old woman, presents herself with a series of symptoms that are commonly related to genitourinary issues. The nuances of her case invite a deeper exploration of her health condition, informed by both subjective and objective data, as well as current evidence-based literature.
In-Depth Analysis of Subjective Data
Subjectively, T.S. has described experiencing a set of symptoms, predominantly increased frequency of urination, pain, and urgency. These symptoms have been ongoing for two days, and she has not sought any interventions yet. Her history of having similar symptoms and the recent introduction of a new sexual partner play a crucial role in the diagnosis. While the provided subjective data gives an overview of her condition, a comprehensive assessment should delve deeper to enhance the understanding: Genitourinary Assessment Analysis Assignment Paper
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- Nature of Pain: Descriptions like ‘burning,’ ‘stabbing,’ or ‘aching’ can provide more context.
- Associated Symptoms: Inclusion of factors like hematuria or lower abdominal pain.
- Sexual History: Any known STIs, her partner’s sexual health history, and previous partners’ health can be pivotal.
- Protection and Contraceptives: Barrier methods and any recent changes in contraceptive methods could be relevant.
- Menstrual History: Menstrual irregularities, if any, should be documented.
Objective Data Analysis
The objective data indicates elevated heart rate (tachycardia) and a slight increase in body temperature, which can suggest an underlying infectious process. The pelvic examination reveals tenderness in the suprapubic area, which aligns with UTI symptoms.
However, this data can be expanded upon:
- Physical Examination: Inspection of the external genitalia, signs of dehydration, or visible distress can offer insights.
- Abdominal Palpation: Kidney tenderness or any palpable masses can inform the diagnosis.
- Lab Results: Detailed urinalysis results can point towards infection, and STI results can confirm or negate suspicions of sexually transmitted infections. Genitourinary Assessment Analysis Assignment Paper
Validating the Assessment
The immediate assessment points towards UTI, which is consistent with both subjective and objective findings. A history of a new sexual partner puts her at risk for STIs, but without concrete evidence, an STI cannot be confirmed (Gupta et al., 2001).
Evaluating Diagnostic Tests:
Diagnostic tests play a crucial role in confirming or refuting any clinical suspicions. For T.S., urinalysis would provide clarity about the presence of leukocytes, nitrites, and bacteria, which are indicative of UTIs. STI tests, considering her new sexual partner, would rule out any underlying infections that might present with similar symptoms.
Acceptance/Rejection of Diagnosis
The UTI diagnosis aligns well with the available data. However, holding onto the STI diagnosis until confirmed by testing is the prudent approach. STIs have significant implications, and a confirmed diagnosis would require partner notification and treatment (Workowski & Bolan, 2015). Genitourinary Assessment Analysis Assignment Paper
Alternative Diagnoses to Consider:
- Interstitial Cystitis: Also known as painful bladder syndrome, its symptoms often mimic UTIs (Cox et al., 2016).
- Pyelonephritis: Flank pain, feverish feeling, and UTI symptoms could suggest a kidney infection (Czaja et al., 2007).
- Overactive Bladder: Although it presents without pain, urgency and frequency are hallmark symptoms (Abrams et al., 2010).
In Summary, T.S.’s presentation warrants a thorough evaluation. While UTI stands out as a likely diagnosis, it is crucial not to tunnel vision on it. It is essential to rule out other potential diagnoses and ensure that T.S. receives holistic care.
References
Abrams, P., Cardozo, L., Fall, M., Griffiths, D., Rosier, P., Ulmsten, U., … & Wein, A. J. (2010). The standardization of terminology of lower urinary tract function: report from the standardization sub-committee of International Continence Society. In Textbook of Female Urology and Urogynecology (pp. 1098–1108). CRC Press.
Cox, A., Golda, N., Nadeau, G., Nickel, J. C., Carr, L., Corcos, J., & Teichman, J. (2016). CUA guideline: Diagnosis and treatment of interstitial cystitis/bladder pain syndrome. Canadian Urological Association Journal, 10(5-6), E136.
Czaja, C. A., Scholes, D., Hooton, T. M., & Stamm, W. E. (2007). Population-based epidemiologic analysis of acute pyelonephritis. Clinical infectious diseases, 45(3), 273-280.
Gupta, K., Hooton, T. M., & Stamm, W. E. (2001). Increasing antimicrobial resistance and the management of uncomplicated community-acquired urinary tract infections. Annals of Internal Medicine, 135(1), 41–50.
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. Genitourinary Assessment Analysis Assignment Paper
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ASSIGNMENT #1
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: Genitourinary Assessment Analysis Assignment Paper
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.
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Assignment 1
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. Genitourinary Assessment Analysis Assignment Paper
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. Genitourinary Assessment Analysis Assignment Paper
