Week 10: Special Examinations—Breast, Genital, Prostate, and Rectal

Assessing the Genitalia and Rectum

Assessment of the genitalia and rectum is vital in depicting genitourinary and gastrointestinal abnormalities respectively. A rectal examination is necessary to complete an abdominal exam. Meanwhile, assessment of the genitalia is usually sensitive and must be done in the presence of a chaperone. The purpose of this paper is to explore the potential history, physical exam, and differential diagnosis based on a case scenario of T.S. a 32-year-old woman who presents with dysuria, frequency, and urgency for two days. She is sexually active and has had a new partner for the past three months.

Subjective

A triad of urgency, frequency, and dysuria characterizes a pathology that is most likely in the urinary tract. Consequently, it is essential to inquire about associated symptoms such as hematuria, fever, and malaise. Association with malaise and fever is common in urinary tract infections. Similarly, it is important to inquire about the presence of any abnormal vaginal discharge, and burning sensation during urination since she is sexually active and a sexually transmitted infection might be the cause of her symptoms. Likewise, changes in the smell and color of the urine must be elicited as well as associated suprapubic pain. Related to sexually transmitted infections, it is crucial to inquire about the number of sexual partners if similar symptoms have manifested in her partner or the use of protection during intercourse (Garcia & Wray, 2022).

Similarly, her last menstrual period must be known in order to determine if she is pregnant, as this will affect management (Bono et al., 2022). A history of medication use, alcohol, smoking, and illicit drug use must also be obtained. A history of contact with someone who has a chronic cough or TB prior to the onset of the previous symptoms is required, as urogenital TB can present similarly. Finally, any history of trauma or recent urethral catheterization should be inquired about, as these are common risk factors for urinary tract infections.

Objective

The vital signs are mandatory in this patient as it is a pelvic exam. In the general exam, the mental and nutrition status of the patient must be noted. Additionally, a complete abdominal exam must be conducted as the patient has flank pain and suprapubic tenderness. Palpation of the abdomen for any masses and percussion of the flank for costovertebral angle tenderness must be done (Bono et al., 2022). Similarly, complete respiratory and cardiovascular exams must be conducted as a routine during the assessment of any patient. Finally, a digital rectal examination must be performed to exclude associated rectal abnormalities.

Assessment

When a patient exhibits signs of infection, a complete blood count and urine culture must be performed in addition to urinalysis, STI, and pap smear testing. Similarly, a pregnancy test must be performed because urinary tract infections can be exacerbated by pregnancy. She also has no appetite, so a random blood sugar must be taken to rule out hypoglycemia. Similarly, urea, creatinine, and electrolyte tests must be performed to assess renal function in the presence of flank pain. Finally, because the patient has flank pain, which may indicate pyelonephritis, inflammatory markers such as ESR and CRP, as well as blood cultures, must be performed (Bono et al., 2022). Imaging tests are not required to diagnose lower UTI. However, because the patient is experiencing flank pain, a CT scan of the abdomen and pelvis with or without IV contrast, as well as an ultrasound of the kidneys and bladder, are required to identify any pathologies and outline the architecture of the kidney and bladder (Belyayeva & Jeong, 2022)

A urinary tract infection and a sexually transmitted infection are two possible diagnoses. Infections of the bladder, urethra, ureters, or kidneys are referred to as urinary tract infections (Bono et al., 2022). UTIs are more common in women due to a shorter urethra and the close proximity of the anal and genital regions (Bono et al., 2022). The irritative lower urinary tract symptoms are defined by a triad of frequency, dysuria, and urgency (Bono et al., 2022). Suprapubic tenderness is also a common symptom of lower urinary tract infections. However, the patient is also feverish and has flank pain, indicating the possibility of upper urinary tract involvement (Bono et al., 2022). T.S is also sexually active, which puts her at risk for urinary tract infection.

Another possibility is a sexually transmitted infection. T.S is sexually active and has been with her new partner for three months, which is a major risk factor for this condition (Garcia & Wray, 2022). The majority of STIs cause suprapubic pain. Most STIs are asymptomatic, but if they are, they cause urethral discharge, vaginal discharge, pruritus, and pain (Garcia & Wray, 2022). T.S. was critical of the aforementioned characteristics.

Other possibilities include pyelonephritis, interstitial cystitis, and urethritis caused by a STI. Pyelonephritis is a condition that affects the renal pelvis and parenchyma (Belyayeva & Jeong, 2022). It is usually a side effect of an ascending bacterial infection of the bladder and is characterized by frequency, dysuria, urgency, fever, malaise, flank pain, and suprapubic pain (Belyayeva & Jeong, 2022). Interstitial cystitis is a noninfectious chronic cystitis characterized by recurrent suprapubic pain (Daniels et al., 2018). Urgency, frequency, suprapubic discomfort, and pain relieved by urination are all symptoms. T.S. exhibits some of these characteristics, but the gradual onset of symptoms and a duration of more than six weeks are required for the diagnosis of this condition (Daniels et al., 2018). Finally, urethritis caused by a STI can manifest in females as only frequency, urgency, and dysuria with little or no vaginal discharge (Young et al., 2022).

Conclusion

Assessment of the genitalia and rectum is sensitive and may help identify abnormalities of the rectum and genitourinary tract. Most abnormalities of the genitourinary system particularly UTIs and STIs can be diagnosed clinically. Consequently, a comprehensive history and physical examination are mandatory. Most UTIs are common in females. Pregnancy must always be excluded in a patient presenting with features suggestive of a UTI.

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References

Belyayeva, M., & Jeong, J. M. (2022). Acute Pyelonephritis.

Bono, M. J., Leslie, S. W., & Reygaert, W. C. (2022). Urinary Tract Infection.

Daniels, A. M., Schulte, A. R., & Herndon, C. M. (2018). Interstitial cystitis: An update on the disease process and treatment. Journal of Pain & Palliative Care Pharmacotherapy, 32(1), 49–58.

Garcia, M. R., & Wray, A. A. (2022). Sexually Transmitted Infections.

Young, A., Toncar, A., & Wray, A. A. (2022). Urethritis.

Patients often feel awkward discussing genitalia and the rectum with medical professionals, but it is critical to obtain a complete medical history and perform a thorough physical exam. By examining case studies of these anomalies, advanced practice nurses can be better prepared to examine patients with vaginal and rectal disorders.

In this assignment, you will consider case studies that explain remarkable discoveries in patients treated in a clinical setting.

As part of this assignment, you will review a SOAP note case study that outlines abnormal findings in patients encountered in a clinical setting. You will consider what information should be obtained from the patients’ histories, as well as what physical examinations and diagnostic testing should be performed. You will also develop a differential diagnosis using a variety of potential disorders.

GENITALIA EVALUATION

Subjective:

CC: “I want to have the pimples on my bottom looked at.”
HPI: AB, a 21-year-old WF college student, comes to your clinic with external lumps on her genital region. She claims the lumps are scratchy but not painful. She claims to be sexually active and to have had several relationships in the previous year. She had her first sexual encounter when she was 18 years old. She denies having any unusual vaginal discharge. She first noticed the pimples about a week ago, but she’s not sure how long they’ve been there. Her most recent Pap smear test was three years ago, and the results were normal with no abnormalities found. She claims to have had a chlamydia infection about two years ago. She completed the recommended chlamydia treatment course.
PMH: Asthma
Symbicort 160/4.5mcg is a medication.
NKDA allergies
FH: No history of breast or cervical cancer, HTN in both parents, GERD.
Social: Denies using tobacco; etoh on occasion; married; three kids (1 girl, 2 boys)

Objective:

VS: HT 5’10”; WT 169lbs; BP 120/86; RR 16; P 92; Temp 98.6
No murmurs, heartbeat: RRR
Lungs: CTA, symmetrical chest wall
Genital: Female hair is distributed normally; no lumps or swelling are present. Without erythema or discharge, the urethral meatus is intact. intact perineum with an episiotomy scar that has healed. Rugae are present, the vaginal mucosa is pink and wet, and there is a possible firm, circular, tiny, painless ulcer on the external labia.
Abd: mild bowel noises, normal murphy’s, negative rebound, negative McBurney
Obtaining an HSV specimen for diagnosis

Assessment:

Chancre PLAN: This component will be necessary for upcoming courses, but it is not necessary for the assignments in this course (NURS 6512).

To get ready:

Regarding the case study supplied for the SOAP note:

Review the learning resources from this week and give thought to the case study insights they offer.
Think about the history that the patient in the case study would need to provide.
Think about the physical examinations and diagnostic procedures that might be appropriate to learn more about the patient’s condition. How could a diagnosis be made using the findings?
List at least five potential conditions that could be included in the patient’s differential diagnosis.

To finish:

Please refer to the Sullivan text’s Chapter 5. Examine the case study on the SOAP note. Answer the following questions using evidence-based resources, and then back up your responses with recent data from the literature.

Examine the note’s subjective section. List any additional details that the documentation should contain.
Examine the note’s objective section. List any additional details that the documentation should contain.
Do the subjective and objective data support the assessment? Whether or not
Would diagnostics be appropriate in this situation, and how would a diagnosis be made using the findings?
Would you disagree with the present diagnosis? If not, why not? Name three potential conditions that could be used in this patient’s differential diagnosis. Use at least three distinct references from recent works of evidence-based literature to support your arguments.

One critical element of any physical exam is the ability of the examiner to put the patient at ease. By putting the patient at ease, nurses are more likely to glean quality, meaningful information that will help the patient get the best care possible. When someone feels safe, listened to, and cared about, exams often go more smoothly. This is especially true when dealing with issues concerning breasts, genitals, prostates, and rectums, which are subjects that many patients find difficult to talk about. As a result, it is important to gain a firm understanding of how to gain vital information and perform the necessary assessment techniques in as non-invasive a manner as possible.

In final preparation for this week’s head-to-toe physical examination, you explore how to assess problems with the breasts, genitalia, rectum, and prostate.

Learning Objectives

Students will:

• Evaluate abnormal findings on the genitalia and rectum
• Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the breasts, genitalia, prostate, and rectum
• Assess health conditions based on a head-to-toe physical examination

Photo Credit: Jose Luis Pelaez Inc/Blend Images/Getty Images

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

• • Chapter 16, “Breasts and Axillae” (pp. 350-369)This chapter focuses on examining the breasts and axillae. The authors describe the examination procedures and the anatomy and physiology of breasts.

• • Chapter 18, “Female Genitalia” (pp. 416-465)In this chapter, the authors explain how to conduct an examination of female genitalia. The chapter also describes the form and function of female genitalia.

• • Chapter 19, “Male Genitalia” (pp. 466-484)The authors explain the biology of the penis, testicles, epididymides, scrotum, prostate gland, and seminal vesicles. Additionally, the chapter explains how to perform an exam of these areas.

• Chapter 20, “Anus, Rectum, and Prostate” (pp. 485-500)This chapter focuses on performing an exam of the anus, rectum, and prostate. The authors also explain the anatomy and physiology of the anus, rectum, and prostate.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

• • Chapter 5, “Amenorrhea” (pp. 47-60)Amenorrhea, or the absence of menstruation, is the focus of this chapter. The authors include key questions to ask patients when taking histories and explain what to look for in the physical exam.

• • Chapter 6, “Breast Lumps and Nipple Discharge” (pp. 61-72)This chapter focuses on the important topic of breast lumps and nipple discharge. Because breast cancer is the most common type of cancer in women, it is important to get an accurate diagnosis. Information in the chapter includes key questions to ask and what to look for in the physical exam.

• • Chapter 7, “Breast Pain” (pp. 73-80)Determining the cause of breast pain can be difficult. This chapter examines how to determine the likely cause of the pain through diagnostic tests, physical examination, and careful analysis of a patient’s health history.

• • Chapter 27, “Penile Discharge” (pp. 318-324)The focus of this chapter is on how to diagnose the causes of penile discharge. The authors include specific questions to ask when gathering a patient’s history to narrow down the likely diagnosis. They also give advice on performing a focused physical exam.

• • Chapter 36, “Vaginal Bleeding” (pp. 419-433)In this chapter, the causes of vaginal bleeding are explored. The authors focus on symptoms outside the regular menstrual cycle. The authors discuss key questions to ask the patient, as well as specific physical examination procedures and laboratory studies that may be useful in reaching a diagnosis.

• Chapter 37, “Vaginal Discharge and Itching” (pp. 434-445)This chapter examines the process of identifying causes of vaginal discharge and itching. The authors include questions on the characteristics of the discharge, the possibility of the issues being the result of a sexually transmitted infection, and how often the discharge occurs. A chart highlights potential diagnoses based on patient history, physical findings, and diagnostic studies.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

• Chapter 3, “Adult Preventative Care Visits” (“Gender Specific Screenings”; p. 137)

Note: Download the Physical Examination Objective Data Checklist to use as you complete the Head-to-Toe Physical Assessment Video 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. This Physical Examination Objective Data Checklist was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

Cucci, E. Santoro, A., DiGesu, C., DiCerce, R., & Sallustio, G. (2015). Sclerosing adenosis of the breast: Report of two cases and review of the literature. Polish Journal of Radiology, 80, 122–127. doi:10.12659/PJR.892706. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4356184/

Sabbagh, C., Mauvis, F., Vecten, A., Ainseba, N., Cosse, C., Diouf, M., & Regimbeau, J. M. (2014). What is the best position for analyzing the lower and middle rectum and sphincter function in a digital rectal examination? A randomized, controlled study in men. Digestive and Liver Disease, 46(12), 1082–1085. doi:10.1016/j.dld.2014.08.045

Retrieved from the Walden Library Databases.

Westhoff, C. L., Jones, H. E., & Guiahi, M. (2011). Do new guidelines and technology make the routine pelvic examination obsolete? Journal of Women’s Health, 20(1), 5–10.

Retrieved from the Walden Library databases.

This article describes the benefits of new technology and guidelines for pelvic exams. The authors also detail which guidelines and technology may become obsolete.

Centers for Disease Control and Prevention. (2012). Sexually transmitted diseases (STDs). Retrieved from http://www.cdc.gov/std/#

This section of the CDC website provides a range of information on sexually transmitted diseases (STDs). The website includes reports on STDs, related projects and initiatives, treatment information, and program tools.

University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial. Retrieved from http://www.med-ed.virginia.edu/courses/rad/index.html

This website provides an introduction to radiology and imaging. For this week, focus on genitourinary radiology, as well as the cross-sectional female pelvis and the cross-sectional male pelvis in abdominal radiology.

Required Media

Online media for Seidel’s Guide to Physical Examination

It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 16 and 18–20 that relate to special examinations, including breast, genital, prostate, and rectal. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/.

Optional Resources

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

• • Chapter 8, “The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts” (Section 2, “The Breasts,” pp. 434–444)Section 2 of this chapter focuses on the anatomy and physiology of breasts. The section provides descriptions of breast examinations and common breast conditions.

• • Chapter 11, “The Female Genitalia and Reproductive System” (pp. 541–562)In this chapter, the authors provide an overview of the female reproductive system. The authors also describe symptoms of disorders in the reproductive system.

• • Chapter 12, “The Male Genitalia and Reproductive System” (pp. 563–584)The authors of this chapter detail the anatomy of the male reproductive system. Additionally, the authors describe how to conduct an exam of the male reproductive system.
• Review of Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid” (pp. 445–527)

By Day 7

This Assignment is due.

Grading Criteria

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Week 10 Assignment 1 Rubric

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Submit your Week 10 Assignment draft and review the originality report.

Submit Your Assignment by Day 7

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Week 10 Assignment 1

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Assignment 2: Head-to-Toe Physical Assessment Video

Throughout this course, you were encouraged to practice conducting various physical assessments on multiple areas of the body, ranging from the head to the toes. Each of these assessments, however, was conducted independently of one another. For this Assignment, you connect the knowledge and skills you gained from each individual assessment to perform a comprehensive head-to-toe physical examination on a volunteer “patient.”

To prepare:

• Arrange an appropriate time and setting with your volunteer “patient” to perform a head-to-toe physical examination. Note: Your volunteer’s Video Release Form must be submitted prior to the exam. Refer to the Week 1 Looking Ahead for release form details.
• Download and review the Physical Examination Objective Data Checklist from this week’s Learning Resources.
• Ensure that you have the appropriate lighting and equipment to perform the examination.

To complete:

• Record yourself performing the head-to-toe physical examination. Be sure to cover all of the areas listed in the checklist and to use any equipment appropriately.

By Day 7

This Assignment is due. Submit your video using the Kaltura Mashup tool accessible through the Assignment submission link provided.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

• Please save your Assignment using the naming convention “WK10Assgn+last name+first initial.(extension)” as the name.
• Click the Week 10 Assignment Rubric to review the Grading Criteria for the Assignment.
• Click the Week 10 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.
• Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK10Assgn+last name+first initial.(extension)” and click Open.
• If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
• Click on the Submit button to complete your submission.

Grading Criteria

To access your rubric:

Week 10 Assignment Rubric

Submit Your Assignment by Day 7

To submit your Assignment:

Week 10 Assignment

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Week in Review

This week, you culminated the knowledge and skills you gained from each individual assessment of multiple areas of the body to perform a comprehensive head-to-toe examine on your ‘patient’ while recording yourself using Kaltura.

Next week, you will consider how evidence-based practice guidelines and ethical considerations factor into health assessments. In addition, you will evaluate health assessment concepts related to sports physicals and well-child and well-woman examinations.

Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum

Health assessment helps clinicians develop the most effective care plan from clinical reasoning, diagnosis, and treatment of the patient effective, based on the provided information. For instance, when carrying out a genitourinary assessment of a patient, it is very important to base the investigations on the patient’s subjective data and diagnostic examination (Chen & Zeng, 2020). The provided case study for this assignment presents a 32-year-old female patient with a chief complaint of frequency, dysuria, and urgency for the past two days. A thorough health assessment is required for further understanding of the condition the patient is suffering from to promote the development of an appropriate care plan. Hence, this paper aims at exploring additional subjective and objective information necessary to promote the diagnosis process of this patient.

Additional Subjective Information

            The subjective information provided by the patient includes the chief complaint of increased urine frequency, urgency, and painful urination. Following the acronym “OLD CARTS” for further elaboration of the patient’s chief complaint, only the onset, and location of the symptoms have been provided since the patient reports having the above symptoms for the past two days (Kim et al., 2019). However, additional information regarding the patient presenting symptoms such as severity, alleviating, and aggravating factors are also crucial in promoting further understanding of the patient’s condition.

Under current patient medication, the patient reports not taking any medication at the moment for the present condition or any other medical condition. However, information regarding the patient’s allergies and past medical history are missing (Chen & Zeng, 2020). The patient also reports a history of tonsillectomy in 2001, and appendectomy in 2020, which are essential aspects of the patient’s subjective information. The immunization status of the patient is however missing, which is crucial in understanding the cause of the patient’s condition and how it should be managed.

The patient’s social and family history are also missing, which are crucial in determining the risk factors which predispose the patient to certain medical conditions. Additionally, the patient’s reproductive history is also missing, such as the menstrual cycle is also missing, in addition to health maintenance such as eating habits and sleeping patterns (Paladine & Desai, 2018). Finally, the review of systems for this patient is also missing. This information is crucial for further understanding the normal functioning of different body systems, to determine which systems have been affected by the patient’s condition.

Additional Objective Information

            The objective information is usually collected upon conducting a physical examination of the patient while focusing only on pertinent data to the reported patient’s chief complaint. The clinician needs to start by evaluating the patient’s general health by describing their general appearance such as alert, fatigued, or well-groomed (Kim et al., 2019). The patient’s vitals dada has been provided, but still lacks information on the patient’s height and weight which is needed in calculating her BMI and determining if she has an ideal body weight, obese, overweight, or underweight. Cardiovascular and respiratory examination findings are also necessary for determining the functioning of the two systems, of which abnormalities are associated with poor health and increased risk of infections.

Additionally, since the patient presents with symptoms of a genitourinary disease, it is quite crucial to conduct a comprehensive examination of the genitourinary system. Mild tenderness of the suprapubic area was reported, in addition to the absence of vaginal discharge and adnexal tenderness. Upon conducting the pelvic bimanual examination, it was noted that the patient had normal-sized adnexa and uterus with a normal cervix in appearance. In addition to this information, the characteristic of the patient’s urine, in terms of appearance and odor should have also been provided for further understanding of the condition the patient is suffering from (Charvériat & Fritel, 2019). The reported objective information is necessary in guiding the type of diagnostic tests to order to promote an accurate diagnosis of the patient.

Assessment

The provided subjective and objective information relatively supports the assessment of the patient which suggests the presence of urinary tract infection (UTI). The patient is positive for UTI symptoms such as increased frequency and urgency and pain during urination as demonstrated in the subjective portion of the patient’s history. Additional UTI symptoms include foul-smelling and cloudy urine among others (Paladine & Desai, 2018). The objective portion of the patient history on the other hand reveals mild tenderness in the suprapubic region which might have resulted from urine retention confirming the presence of an infection. However, urinalysis and urine culture are required to confirm this assessment.

Diagnostics Appropriateness

            Given that most genitourinary diseases she common symptoms such as increased urgency and frequency, certain diagnostic tests are needed for the clinician to be able to come up with an accurate diagnosis. Such tests include urinalysis, to assess for the presence of a bacteria, virus, or any other causative microorganism (Kim et al., 2019). A urine culture is needed to determine the type of bacteria causing the infection. Consequently, a cystoscopy test is also necessary to examine infections of the urethra and bladder and determine the cause of the urinary tract infection.

Differential Diagnosis

            Based on the provided information, I would accept the current UTI diagnosis, which is supported by symptoms such as increased urine frequency, dysuria, and urgency for two days. Physical examination findings such as mild tenderness in the suprapubic region also confirm the presence of an infection. However, I would order urinalysis and urine culture to identify the actual causative microorganisms and confirm the primary diagnosis ad rule out the differential diagnosis (Johnson & Russo, 2018). Some of the differential diagnoses include vaginitis, pyelonephritis, and pelvic inflammatory disease (PID).

Vaginitis is an inflammatory condition of the vagina characterized by pain, itchiness, and discharge. It is usually caused by an infection or change in the balance of the vaginal normal flora. The patient is positive for pain during urination (Paladine & Desai, 2018). However, according to the Amsel criteria, the diagnosis of vaginitis requires the presence of clue cells on microscopy of vaginal fluid, vaginal pH higher than 4.5, milky discharge, and a positive whiff test.

Pyelonephritis or kidney infection is a type of UTI which normally starts in the patient’s bladder or urethra and travels to both or one of the patient’s kidneys (Johnson & Russo, 2018). Patients with this disease normally present with frequent urination, and pain during urination, just like the patient in the provided case study in addition to other symptoms such as fever, fatigue and nausea, and vomiting. Urinalysis or culture is required to confirm this diagnosis, in addition to the patient presenting symptoms as demonstrated above.

            Finally, PID is an infection that normally affects the female reproductive organs. It usually occurs when sexually transmitted bacteria travel from the patient’s vagina to the uterus, fallopian tube, or even ovaries (Charvériat & Fritel, 2019). The patient in the provided case study is sexually active and recently changes a sex partner which puts her at risk of this infection. Patients diagnosed with this disease normally present with symptoms such as painful urination, pain during sex, nausea, vomiting, fever, chills, irregular menstrual periods, and abnormal vaginal discharge. To confirm the diagnosis of PID, an endometrial biopsy with histopathologic evidence suggesting endometritis is required. Transvaginal sonography and magnetic resonance imaging of the patient’s pelvic area may also be required to confirm this diagnosis.

Conclusion

The female patient in the provided case study presents to the clinic complaining of increased frequency, pain with urination, and urgency. Associated symptoms include lack of appetite, flank pain, and pelvic discomfort. These symptoms suggest a UTI diagnosis, however, additional subjective and objective information is required to confirm this diagnosis. Several diagnostic tests also needed to be ordered to rule out the differentials and come up with the primary diagnosis. Such tests include cystoscopy tests, urine tests, and urine culture. The possible differential diagnosis includes vaginitis, Pyelonephritis, and PID.

 

 

References

Charvériat, A., & Fritel, X. (2019). Diagnosis of pelvic inflammatory disease: clinical, paraclinical, imaging, and laparoscopy criteria. CNGOF and SPILF pelvic inflammatory diseases guidelines. Gynecologie, Obstetrique, Fertilite & Senologie, 47(5), 404-408. DOI: 

Chen, J., & Zeng, R. (2020). Frequency, Urgency, and Dysuria. In Handbook of Clinical Diagnostics (pp. 75-76). Springer, Singapore. https://doi.org/10.1007/978-981-13-7677-1_24

Johnson, J. R., & Russo, T. A. (2018). Acute pyelonephritis in adults. New England Journal of Medicine, 378(1), 48-59. https://doi.org/10.1056/nejmx180009

Kim, W. B., Lee, S. W., Lee, K. W., Kim, J. M., Kim, Y. H., & Kim, M. E. (2019). How Women Evaluate Syndromic Recurrent Urinary Tract Infections. Urogenital Tract Infection, 14(2), 46-54.

Paladine, H. L., & Desai, U. A. (2018). Vaginitis: diagnosis and treatment. American family physician, 97(5), 321-329. PMID: 29671516