Enhancing Diagnostic Precision: A Comprehensive Approach to Genitourinary Assessment and Diagnostic Reasoning
Instructions
Write a narrative explanation by answering the questions. Please use APA format. DO NOT WRITE THE SOAP NOTE. All you need to do is write a narrative paper answering the questions following the APA format.
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 five 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
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 had 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 adnexa
no adnexal tenderness.
No vaginal discharge is noted.
The cervix appears normal.
Diagnostics: Urinalysis, STI testing, Pap smear
Assessment:
UTI
STI
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Solution
Advanced Health Assessment and Diagnostic Reasoning
A healthcare provider collects both subjective and objective data in order to understand a patient’s medical history and identify pathophysiological changes that can be associated with particular diagnoses. The assessment or diagnosis that the healthcare provider arrives at must be supported by both objective and subjective data (Dains et al., 2019). This explains why it is important to collect sufficient data to guide accurate decision-making.
Subjective Portion
The subjective portion of a SOAP note is where the healthcare provider documents medical history as reported by the patient. The data provided under the subjective portion of the given SOAP note is inadequate to help a clinician to make a proper diagnosis. Data to be added to this section should include the patient’s report in relation to family history, social history, and assessment findings of various body systems including the head, eyes, ears, nose, and throat (HEENT), skin, integumentary, cardiovascular, respiratory, urogenital, musculoskeletal, neurologic, psychiatric, endocrine, and hematologic systems (Dains et al., 2019).
Objective Portion
The objective portion of a SOAP note is where the healthcare provider documents the results of physical exams. The given objective data is not enough to enable the clinician to make an accurate diagnosis. The specific details to be added to this section are information related to general appearance and physical exam findings for various body organs (Bickley et al., 2020). The organs to be targeted include the skin, HEENT, lymph nodes, breasts, lungs/chest, heart, back, spine, joints, psychiatric, endocrine, hematologic, and neurologic organs.
Assessment: Objective and Subjective Information
The assessment is not supported by both subjective and objective information. The assessment indicates that the patient has UTI or STI. A person with UTI or STI may present with increased frequency and pain with urination (Alrashid et al., 2022; Olaru et al., 2021). Although the assessment might be supported partly by the subjective data, the objective information does not confirm the presence of any of the given diagnoses.
Appropriate Diagnostic Tests and How Results Will Be Used
The healthcare provider should conduct additional diagnostic tests to identify other possible health conditions that the patient might be suffering from. The appropriate diagnostic tests to consider, in addition to the ones already done, are ultrasound imaging and blood sugar test (Turkoglu et al., 2022). These tests should be completed to establish whether the patient has urinary bladder dysfunction and diabetes mellitus respectively (Adegbehingbe al., 2022; Turkoglu et al., 2022). Urinary agency and frequency are common symptoms in patients with urinary bladder dysfunction, diabetes mellitus, and other diseases. Results of the proposed diagnostic tests will be used to rule out or confirm the presence of the suspected diseases.
Rejecting or Accepting the Current Diagnosis
I would reject the current diagnosis. The reason is that it is not supported by both subjective and objective data. Additionally, there is a need to conduct further tests which might reveal other possible health conditions (Bickley et al., 2020).
Differential Diagnoses
- Urinary tract infection: The presence of dysuria, frequency, and urgency (Alrashid et al., 2022)
- Sexually transmitted disease: Sexually transmitted diseases such as acute bacterial cystitis can cause dysuria, frequency, and urgency. Vaginal discharge often occurs in the affected patients (Olaru et al., 2021).
- Diabetes: Urinary urgency, frequency, and nocturia are common symptoms in patients with diabetes mellitus. Dysuria occurs in diabetic patients with a urinary tract infection (Adegbehingbe al., 2022)
- Urinary bladder dysfunction: Urinary urgency, frequency, and incontinence are the primary symptoms. However, dysuria is normally absent in these patients (Adegbehingbe al., 2022)
- Bladder cancer: Dysuria, urgency, and frequency also occur in bladder cancer. Hematuria is the primary symptom of bladder cancer (Omorphos et al., 2021).
References
Adegbehingbe, O. O., Ayoola, O., Soyoye, D., & Adegbehingbe, A. (2022). Urinary bladder wall thickness in type 2 diabetes mellitus patients. Journal of Ultrasonography, 22(88), e12–e20. https://doi.org/10.15557/JoU.2022.0003
Alrashid, S., Ashoor, R., Alruhaimi, S., Hamed, A., Alzahrani, S., & Al Sayyari, A. (2022). Urinary tract infection as the diagnosis for admission through the emergency department: Its prevalence, seasonality, diagnostic methods, and diagnostic decisions. Cureus, 14(8), e27808. https://doi.org/10.7759/cureus.27808.
Bickley, L., Szilagyi, P., Hoffman, R., & Soriano, R. (2020). Bate’s guide to physical examination and history taking (Lippincott Connect). 13th ed. Philadelphia: Wolters Kluwers.
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.
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. https://doi.org/10.1136/bmjopen-2021-050407
Omorphos, N. P., Piedad, J., & Vasdev, N. (2021). Guideline of guidelines: Muscle-invasive bladder cancer. Turkish Journal of Urology, 47(Supp. 1), S71–S78. https://doi.org/10.5152/tud.2020.20337
Turkoglu, A., Coskun, A., Arinkan, S. A., & Vural, F. (2022). The role of transperineal ultrasound in the evaluation of stress urinary incontinence cases. International Brazilian Journal of Urology: Official Journal of the Brazilian Society of Urology, 48(1), 70–77. https://doi.org/10.1590/S1677-5538.IBJU.2020.1100