Assessing The Genitalia and Rectum Soap Note Example

Patients are frequently uncomfortable discussing with healthcare professionals 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.


Assessing the Genitalia and Rectum

The 32-year-old female patient T.S. reports to the hospital with a chief complaint of increased frequency and pain with urination. The patient says that she had these symptoms of dysuria, frequency, and urgency years ago, but they returned two days ago. She reports that she has not tried anything to relieve the pain and has been sexually active with a new partner for the past three months. She has no relevant medical history but reports a surgical history of Tonsillectomy in 2001 and Appendectomy in 2020.

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Subjective, Objective, and Diagnostics

The subjective assessment covers the chief complaint’s duration and past medical history. However, it is essential to assess the patient on the timing of the symptoms by enquiring whether the symptoms vary during different days, times, or activities (Olatunde, 2019). The assessment should enquire about the aggressiveness of these symptoms since they commenced. Has the frequency and pain during urination increased or increased since it was first felt? The subjective assessment should include information on any medications, including over-the-counter supplements, to rule out the possibility of side effects from medications (Olatunde, 2019). Subjective assessment should analyze other health symptoms, such as fever, chills, and nausea, to rule out underlying conditions.

The vital signs and pelvic exam are essential objective assessments in the clinical reasoning for a patient with the chief complaint of increased frequency and pain with urination. However, it is necessary to administer a physical exam, including a genital exam, to assess for inflammation and any infections in the urinary tract (Roth et al., 2019). The subjective and objective information supports the assessment. All the results signify infection in the urinary tract, which supports the assessment of UTI and STI.

According to the symptoms, subjective, and objective information, Urinalysis, STI testing, and pap smear diagnostics are the correct decisions. However, to be on the safe side and to rule out any underlying conditions, it is advisable to do a blood test and relevant imaging studies (Roth et al., 2019). The blood test is essential in ruling out underlying infections in the body and possible inflammation. A CT scan or an ultrasound effectively analyzes any abnormalities in the urinary tract or obstructions that might be unnoticed with other tests (Rosier, 2020).

Differential Diagnosis

According to the subjective information, objective information, and diagnostics results, I would accept the diagnosis of UTI and STI. All the information shows infection in the urinary tract, which might be caused by bacteria entering the tract or results of STI infection. STIs such as Chlamydia and gonorrhea have similar symptoms of frequency and pain with urination (Olaru et al., 2021). The symptoms and assessment results also indicate a differential diagnosis of Interstitial Cystitis, a recurrent bacterial infection. The patient submits that the symptoms have affected her in the past, which shows that the diagnosis might be a recurrent infection (Olaru et al., 2021). Interstitial Cystitis has similar symptoms of frequency, urgency, and pain with urination. Another possible differential diagnosis is vaginal infections such as bacterial vaginosis. Vaginal infections have similar symptoms of pain, frequency, and burning during urination (Rosier, 2020). Another differential diagnosis is urinary tract abnormalities such as obstructions or swelling which might have symptoms of frequency and pain with urination (Rosier, 2020).


Olaru, I. D., Chisenga, M., Yeung, S., Mabey, D., Marks, M., Chonzi, P., Masunda, K. P., Machiha, A., Ferrand, R. A., & Kranzer, K. (2021). Sexually transmitted infections and prior antibiotic use as important causes for negative urine cultures among adults presenting with urinary tract infection symptoms to primary care clinics in Zimbabwe: a cross-sectional study. BMJ Open, 11(8), e050407.

Olatunde, O. (2019). Education Program for Critical Care Nurses on Preventing Catheter-Associated Urinary Tract Infections – ProQuest.

Rosier, P. (2020). Is recurrent urinary tract infection in women associated with abnormalities in lower urinary tract function? A large cohort comparison. European Urology Open Science, 19, e1296–e1297.

Roth, J. D., Pariser, J. J., Stoffel, J. T., Lenherr, S. M., Myers, J. B., Welk, B., & Elliott, S. P. (2019). Patient subjective assessment of urinary tract infection frequency and severity is associated with bladder management method in spinal cord injury. Spinal Cord, 57(8), 700–707.


Soap Note to Analyze: Genitalia Assessment listed below.

Also, it will be important for you to actually copy and paste the assessment directly into the “Course Announcements” section of the course.

Genitourinary Assessment

CC: Increased frequency and pain with urination


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


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



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