Week 10: Special Examinations—Breast, Genital, Prostate, and Rectal
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.
For this week, 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
Learning Resources
Required Readings (click to expand/reduce)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 17, “Breasts and Axillae”
This chapter focuses on examining the breasts and axillae. The authors describe the examination procedures and the anatomy and physiology of breasts.
Chapter 19, “Female Genitalia”
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 20, “Male Genitalia”
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 21, “Anus, Rectum, and Prostate”
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. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 5, “Amenorrhea”
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”
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”
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”
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”
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”
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, “SOAP Notes” (Previously read in Week 8)
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
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.
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. (2019). 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.
Assignment: Lab Assignment: Assessing the Genitalia and Rectum
Photo Credit: Getty Images
Patients are frequently uncomfortable discussing with healthcare professional’s 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.
To Prepare
Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
Based on the Episodic note case study:
Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.
Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
Consider what history would be necessary to collect from the patient in the case study.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
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.
By Day 7 of Week 10
Submit your Assignment.
Document: Final Exam Review (Word document)
Week 10: Special Examinations—Breast, Genital, Prostate, and Rectal GENITALIA ASSESSMENT
Subjective: • CC: “I have bumps on my bottom that I want to have checked out.”
• HPI: AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner during the past year. Her initial sexual contact occurred at age 18. She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.
• PMH: Asthma • Medications: Symbicort 160/4.5mcg • Allergies: NKDA • FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD • Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective: • VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs • Heart: RRR, no murmurs • Lungs: CTA, chest wall symmetrical • Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia • Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, negMcBurney • Diagnostics: HSV specimen obtained Assessment: • Chancre 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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Assessing the Genitalia and Rectum
Name
Academic Institution
Assessing the Genitalia and Rectum
Subjective Portion
The 21-year-old WF college student reports to the health facility complaining of bumps on her bottom. The patient has a history of chlamydia, although it was diagnosed and treated. The bumps could be as a result of the occurrence of the condition. However, additional information is required to assess if chlamydia was treated successfully (Ferrari at al., 2018). Additionally, the patient is currently suffering from asthma and managing it appropriately using Symbicort 160/4.5mcg. Asthma is less likely to cause the bumps on her bottom.
The patient has revealed that she has multiple sexual partners for the last year. The multiple sex partners could expose the patient to a risk of viral or bacterial infection (Ferrari et al., 2018). In the infection could STIs which can lead to the bumps. However, the subjective portion requires more information to ensure substantial data is available to narrow down to one condition.
Additional Information
The additional information should clarify the color, shape, and size of the bumps. The patient should also describe if the bumps are wet or dry. The description of the bumps will be used to assess for a possible viral or bacterial infection related to STI such as herpes or syphilis (Piret & Boivin, 2016). The patient also needs to confirm the health condition of the sexual partners. For instance, they should confirm if they have a homosexual partner. The confirmation will reveal the possible health risks facing the patient.
The patient needs to confirm if they taking any supplement or drug to enhance sexual activity, maintain body weight, or reenergize the body. The drugs could cause irritation to the skin thus leading to the bumps. The subjective portion should also include information on whether the patient has a history of skin disease. Additionally, the social lifestyle of the patient should confirm their living conditions. For instance, if they live in a dorm together with the spouse or children. The cleanliness of the living space should be confirmed. The workplace should also be assessed to ensure it has no chemical irritants that can cause the bumps. On the other hand, the information should describe the last menstrual period and if there was an issue with the period (Piret & Boivin, 2016). The health information of the reproductive parts will also include any bleeding or discharge.
Objective Portion
The objective portion shows that the patient has normal health conditions including the temperature, blood pressure, respiratory rate, and height. However, subjective information is not conclusive for a critical assessment. It requires additional information to confirm the body mass index. The patient also shows they have no urethral meatus or discharge. Therefore, further assessment of the condition is necessary (Dains, Baumann & Scheibel, 2018). The objective information will also provide an opportunity to carry out extensive diagnostic tests.
Additional Information
The objective portion requires additional information to accurately assess the health condition of the patient. One of the areas to assess is the skin for any lesion, bruising, lesions or plaques. It will check for redness, scaling, skin plaques, discoloration or patches. The information will also assess if the patient has any allergic reactions to chemicals, seasonal changes, temperature, water or soap. The general information will also be required to confirm if the patient is alert, aware, and oriented (Dains, Baumann & Scheibel, 2018). The hygiene of the patient will also reveal more details about their health condition. Additionally, the information should confirm the body mass index of the patient to determine if the weight and height are proportional. The details about how the temperature and blood pressure were assessed are also critical in the analysis.
Subjective and Objective Information
The subjective and objective information does not accurately support the assessment of the health condition. Additional information is necessary to confirm the health condition of the patient, rule out less likely illnesses and narrow down to one disease. The additional information is also critical to fill the gaps in the initial information provided by the patient. For instance, the patient needs to describe the bumps in terms of their color, shape and pattern and confirm if they have any discharge. Syphilis, one of the suspected conditions round, firm, painless, open, and wet bumps (Tsevat, Wiesenfeld, Parks & Peipert, 2017). The medical history information should also be supplemented with information on whether such bumps were available when the patient suffered from chlamydia. Details about whether chlamydia was successfully treated should also be confirmed. The unavailability of critical information makes it less likely to accurately confirm the diagnosis.
Diagnostic Tests
The diagnostic tests that will be carried out will be largely to check for a viral infection especially for STIs. The tests related to sexually transmitted illnesses are crucial due to the multiple sexual partners in the last year (Ferrari et al., 2018). A Polymerase chain reaction (PCR) is necessary to check for HIV genetic material. A serum HCG test is critical to confirm if the patient is pregnant or not (Piret & Boivin, 2016). Another test necessary for the assessment is the acetic acid test which is used to check for human papillomavirus. KOH wet mount and litmus will also be used to check for changes in the pH levels in the genitals. Scrapping tests and syphilis serology will check for syphilis (Silvestre, Romero-Pérez & Encabo-Durán, 2017). Other tests include a nontreponemal test, enzyme-linked immunosorbent assay, venereal disease research laboratory test, rapid plasma regain.
A tzanck smear is necessary to confirm herpes virus or chickenpox. Another test that is required is the Nucleic Acid Amplification Test (NAATs) which is used to test for gonorrhea and chlamydia (Tsevat, Wiesenfeld, Parks & Peipert, 2017). NAATs will be followed by a pelvic examination to check for any abnormalities. They will also be supplemented by UA test which is useful in testing for gonorrhea and chlamydia. HSV specimens will also be collected to carry out a battery of viral culture tests (Ferrari et al., 2018). The tests are necessary for identifying any viral or bacterial infection.
Differential Diagnosis
The differential diagnosis will comprise of various diseases including syphilis, acute dermatitis, insect bite, herpes progenitalis (Simple II), and herpes progenitalis with asymptomatic chlamydia.
1. Syphilis – Syphilis is a bacterial infection that is transmitted through sexual contact. The symptoms include sores around genitals, rectum, and mouth. The sores are firm, round, and painless. The condition can be diagnosed using tests such as serology which is used to check for the stage of the condition (Ferrari et al., 2018). Other tests may be required including scrapping. The condition has a higher likelihood is due to the multiple sexual partners of the patient. However, additional information is required before making conclusions about the diagnosis.
2. Herpes progenitalis (Simple II) – Herpes progenitalis (Simple II) is one of the common sexually transmitted diseases. The likelihood is high due to the sexual partners who could be infected. The diagnosis of herpes progenitalis (Simple II), requires PCR test and scrapping. A physical examination is also necessary to establish the physical changes around the genitals and rectum (Piret & Boivin, 2016). A primary infection spreads extensively while a reoccurrence is localized in one area. The condition causes a burning sensation especially while urinating or having intercourse. Therefore, additional information is still required before diagnosing the patient.
3. Insect bite – An insect bite is itchy, red, and swollen. The swollen area may have a fluid called weal. A physical examination combined with the medical and social history of the patient can be used to confirm an insect bite (Dains, Baumann & Scheibel, 2018). Insect bites are common depending on the living conditions of a patient. The patient should confirm if they have been camping or bathing outdoors recently. However, the condition is less likely especially if the insect bite is in the bottom and not other familiar parts like face or arms.
4. Herpes progenitalis with asymptomatic chlamydia – The condition is a possible illness due to the history of chlamydia and sexual behavior with multiple sexual partners (Piret & Boivin, 2016). However, additional information should be gathered including the medical history plus diagnostic tests to check for viral or bacterial infection. An insect bite causes itching, redness, and swelling. Weal fluid may be present in the swollen area. A physical examination combined with the patient’s medical and social history can be used to confirm an insect bite (Dains, Baumann & Scheibel, 2018). Insect bites are common depending on a patient’s living conditions. The patient should confirm whether or not they have recently gone camping or bathing outside. However, the condition is less likely, particularly if the insect bite is in the bottom rather than other familiar areas such as the face or arms.
4. Herpes progenitalis with asymptomatic chlamydia – Due to a history of chlamydia and sexual behavior with multiple sexual partners, the condition is a possible illness (Piret & Boivin, 2016). However, additional information, such as a medical history and diagnostic tests to rule out viral or bacterial infection, should be gathered.
5. Acute dermatitis – Acute dermatitis causes an irritable, swollen, blistering skin rash. The condition can be caused by irritants. A health practitioner requires to carry out physical examination plus collect past medical information to diagnose the condition (Dains, Baumann & Scheibel, 2018). The diagnosis requires all the missing information to be collected for accurate analysis of the condition.
References
Dains, J. E., Baumann, L. C., & Scheibel, P. (2018). Advanced Health Assessment & Clinical Diagnosis in Primary Care E-Book. Elsevier Health Sciences.
Ferrari, R. L., De Andrade, J. C., Chagas, W., Ramos, M. E. B., Freire, N. D. A., Maciel, R. D. M., & Israel, M. S. (2018). Syphilis diagnosis from multiple flat condyloma of the mouth: a case report. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, 126(3), e55.
Piret, J., & Boivin, G. (2016). Antiviral resistance in herpes simplex virus and varicella-zoster virus infections: diagnosis and management. Current Opinion in Infectious Diseases, 29(6), 654-662.
Silvestre S. J. F., Romero-Pérez, D., & Encabo-Durán, B. (2017). Atopic dermatitis in adults: a diagnostic challenge. J Investig Allergol Clin Immunol, 27(2), 78-88.
Tsevat, D. G., Wiesenfeld, H. C., Parks, C., & Peipert, J. F. (2017). Sexually transmitted diseases and infertility. American Journal of Obstetrics and Gynecology, 216(1), 1-9.
