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
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.
Document: Final Exam Review (Word document)
Optional Resource
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)
Required Media
Special Examinations – Breast, Genital, Prostate, and Rectal – Week 10 (14m)
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/
Assignment: Lab Assignment: Assessing the Genitalia and Rectum
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
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Week 10 Assignment Sample Paper
NURS 6512 Week 10 Assignment – Special Examinations—Breast, Genital, Prostate, and Rectal
Special Examinations-Breast, Genital, Prostate, and Rectal
Student’s Name:
Institutional Affiliation:
Additional Subjective Data
During the physical examination, the nurse should conduct a more detailed analysis of the symptoms to determine their size, shape, color, and pattern. The patient should be asked to give a more detailed description of her symptoms. The patient will be asked whether it is the first time she is experiencing the signs, or she has had them previously. If it is not the first time, she will be asked to describe when she last experienced them and the medication used to manage the previous episodes. The nurse should enquire whether the patent has noticed the bumps in any other body part other than the genitals, such as the skin (Ball, Dains, Flynn, Solomon & Stewart, 2014).
Sometimes bumps in the genitourinary tract are associated with other general conditions. Therefore, the physician should check for other conditions such as the presence of skin rash, recent weight loss, loss of body hair, a fever, sores on the anus, dysuria, fatigue, and muscle aches.
The patient will be asked whether any of her sex partners had had the symptoms, what she was doing when she noticed the bumps, and whether her house is infested with parasites such as lice or scabies. The nurse should also enquire whether the patient has experienced any itching or burning currently or before noticing the bumps.
It will also be essential to determine whether the bumps have looked the same all week or their appearance has changed and whether they are spreading, present 100% of the time, or do they come and go. The patient should report if she is aware of anything that aggravates the bumps or decreases the number of cracks and whether she has tried home remedies and what outcomes were achieved.
The patient should be asked about exposure to genital bump risk factors such as douching, use of scented and medicated genital soaps, lotion, and sanitary pads.
Under the past medical history, the patient should be asked about any recent surgeries or procedures requiring anesthesia, recently started medications and the drugs that were prescribed for her previous chlamydia infection. The physician should inquire whether the patient has any skin conditions, allergies, a full course of immunization, and the age of asthma diagnosis.
The medical history should also entail the patient’s gynecological history regarding menstrual onset, frequency, duration, volume, date of last menstrual period, contraception use, and HIV status. It helps eliminate hormonal imbalance, pregnancy, and HIV, which could be responsible for genital bumps.
On the sexual history, the patient’s preference for risky sexual practices such as unprotected sex, anal sex, and multiple sexual partners, should be documented t determine the exposure to STD risk factors. The client’s occupational history is very significant in determining exposure to STD risk factors (Westhoff, Jones & Guiahi, 2011).
Additional Objective Data
Documentation of the overall patient’s appearance regarding the level of cleanliness and grooming helps determine the level of body hygiene, which could be a factor in the development of genital bumps.
HEENT exam should also entail throat assessment to check for redness, drainage, edema, enlarged tonsils, cold sores, lesions, and nodal tenderness. It should also entail cervical evaluation to check for enlarged cervical nodes. A mouth examination to check for mouth sores is also essential. These assessments help in determining the presence of viral infection.
The Chest exam should also check for non-labored breathing, enlarged axillary nodes, discharge, and tenderness over the nipples, which could also be signs of viral infection.
In the genito-urinary exam, it would be essential to assess for cervix tenderness, vaginal bleeding, and foul-smelling vaginal discharge. A rectal exam to ascertain any lesions, hemorrhoids, masses, and trauma is also necessary.
Do Subjective and Objective Data support the Assessment?
The patient was diagnosed with Chancre, a highly infectious painless ulcer, which is a primary stage of syphilis. A chancre is a sexually transmitted infection that usually develops over the genital area. In females, chancres can also present over the vagina, anus, or the vulva and take between 3 weeks to 3 months to show after infection.
Subjective data support the diagnosis because the patient reportedly noticed a painless and rough lump over her genital area and reported no vaginal discharge. She also said to be sexually active, have more than one sex partner, which increases her risk of a sexually transmitted infection. Objective data also support the diagnosis. The objective data ascertain that the client had around, a small painless ulcer on the external labia. Additionally, the performed HSV specimen test is the primary diagnostic test for chancre. However, other HEET examinations were normal (Cucci, Santoro, Di Gesù, Cerce & Sallustio, 2015).
The Relevance of Diagnostics and Its Use to Make a Diagnosis
The diagnostics approach used in this case was an HSV specimen, which was sent to the lab for viral culture. The test is relevant in this case because it assesses for the presence of bacteria Haemophilus ducreyi, which is the chancre causative agent. Additional diagnostics are crucial to rule out the differential diagnosis since many STDs present with similar symptoms. A Polymerase Chain Reaction can also be done to test for herpes simplex antibodies to confirm the diagnosis of herpes simplex. A serology test should be done to rule out syphilis. To rule out Chlamydia and Gonorrhea, rapid Nucleic Acid Amplification tests should be the most recommended.
Would You Reject or Accept the Current Diagnosis?
I would accept the current diagnosis. This is because the patient presents with chancre clinical presentation, rough and painless bumps on the genitals. The patient also confirms exposure to chancre risk factors, such as a history of chlamydia, multiple sex partners. An HSV specimen culture is also positive for bacteria Haemophilus ducreyi, which is the chancre causative agent (Dains, Baumann & Scheibel, 2018).
Possible Differential Diagnoses
The primary diagnosis, in this case, is chancre. The patient presents with chancre clinical presentation, and an HSV specimen culture is positive for bacteria Haemophilus ducreyi, which is the chancre causative agent.
The most potential differential diagnoses, in this case, include syphilis, herpes simplex II and acute contact dermatitis. These conditions are STD’s and present with clinical presentations and risk factors similar to chancre. Syphilis can, however, be ruled out through a serological test that assesses the presence of Treponema pallidum bacteria, a syphilis causative agent.
Herpes Simplex II also presents with similar symptoms and risk factors as a chancre. However, in Herpes Simplex II, the genital bumps are very painful bumps and lesions with a burning sensation during urination. Diagnostic tests also show the presence of a viral infection.
Squamous cell carcinoma is another differential diagnosis with similar symptoms as a chancre. It is a form of skin cancer. However, laboratory tests show no presence of infection, and a skin biopsy reveals the presence of cancerous cells (Centers for Disease Control and Prevention, 2019).
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2014). Seidel’s Guide to Physical Examination-E-Book. Elsevier Health Sciences.
Centers for Disease Control and Prevention. (2019). Sexually transmitted diseases (STDs)
Cucci, E., Santoro, A., Di Gesù, C., Di Cerce, R., & Sallustio, G. (2015). Sclerosing adenosis of the breast: report of two cases and review of the literature. Polish journal of radiology, 80, 122.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2018). Advanced Health Assessment & Clinical Diagnosis in Primary Care E-Book. Elsevier Health Sciences.
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.
Week 10 Assignment
What’s Coming Up in Module 4?
Next week, you will consider how evidence-based practice guidelines and ethical considerations factor into health assessments. You specifically explore evidence-based practice guidelines and ethical considerations for specific scenarios.
Week 11 Final Exam
Next week, you take your Final Exam, which will cover the topics and resources from Weeks 7, 8, 9, and 10 for this course. Please take the time to review and plan your time accordingly so that you may be better prepared for your exam.
Next Module
To go to the next Module:
Module 4
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