Breast, Genital, Prostate, And Rectal GENITALIA ASSESSMENT
For this 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 at least 5 differential diagnosis with several possible conditions. Please remember to pretend that this is an actual patient and gives as much detail as possible!
CASE STUDY:
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
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)
This article describes the benefits of new technology and guidelines for pelvic exams. The authors also detail which guidelines and technology may become obsolete.
Respond to Mackenzie and Heidi
* by offering additional thoughts regarding the examples shared, Software Development Life Cycle-related issues, and ideas on how the inclusion of nurses might have impacted the example described by your colleagues.
Mackenzie Gray
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The Systems Development Life Cycle (SDLC) is a set of stages used when developing a new information system (Ungvarsky, 2019). The SDLC is a specific plan that helps the team throughout the entire process, from the idea of the system to the implementation (Ungvarsky, 2019). The development of SDLC for a healthcare organization should include a needs assessment that encompasses the needs of the organization’s healthcare workers, including physicians and nurses (McGonigle & Mastrian, 2017). The organization’s needs as a whole need to be represented, so solutions get proposed to meet the needs or address issues (McGonigle & Mastrian, 2017).
The waterfall model is one of the oldest methods used in SDLC and is linear; therefore, the model is sequential, and each stage provides information for the following stage (McGonigle & Mastrian, 2017). The waterfall model has six phases: feasibility, analysis, design, implementation, test, and maintain (McGonigle & Mastrian, 2017). Feasibility helps decide if the project could be initiated and typically addresses the following: technological, economics, legal, operational, and scheduling feasibility (McGonigle & Mastrian, 2017). Operational feasibility specifically helps determine if the project will be effective, meet the set expectations to achieve the goals of the project, or addressing the problem at hand (McGonigle & Mastrian, 2017). The analysis phase helps examine the requirements for the system and business needs (McGonigle & Mastrian, 2017). Analysis is an important step to assess the workflow (McGonigle & Mastrian, 2017). Excluding nurses from these crucial beginning phases could be detrimental to implementing a new health information technology system. Nurses work on the frontlines of healthcare and would be essential to decide if the system is feasible to the operations and workflow. For example, implementing a new EHR could be more cost-conscious; however, the documentation could cause inefficiency in the workflow. The design phase helps the team decide what programs are necessary and discusses how they will interact, how the individual programs work, and what the look or feel will be (McGonigle & Mastrian, 2017). For example, nurses would be great resources to help design and decide specifics to be included in an EHR, as nurses are often documenting several times a shift and on multiple patients. The implementation phase occurs when the designed system is ready to use (McGonigle & Mastrian, 2017). The test phase evaluates the system to ensure the program works as it was designed (McGonigle & Mastrian, 2017). Nurses would be great resources to perform beta testing to ensure the system is adequate and performs as it should. The system must be maintained after the testing phase (McGonigle & Mastrian, 2017).
I have not been included in the selection and planning of a new health information technology system in my nursing practice. Being included in a decision-making process can result in increased satisfaction for workers and improve the overall morale of the organization. A study by Graham-Dickerson et al. (2013) concluded that involving staff nurses in decision-making had a positive impact on the work environment, and nurses reported feeling like part of a team when they were included.
References
Graham-Dickerson, P., Houser, J., Thomas, E., Casper, C., ErkenBrack, L., Wenzel, M., & Siegrist, M. (2013). The value of staff nurse involvement in decision making. Journal of Nursing Administration, 43(5), 286–292. https://doi-org.ezp.waldenulibrary.org/10.1097/NNA.0b013e31828eec15
McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.
Ungvarsky, J. (2019). Systems development life cycle (SDLC). Salem Press Encyclopedia of Science. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=ers&AN=119214383&site=eds-live&scope=site
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Heidi
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Nurses should be a part of the system development life cycle for many reasons. Nurses can bring a variety of different references to the team. They can provide their expertise in patient care to develop a successful program.
1. Planning-Software innovation requires collaboration with a team of people to understand what needs are to be met and how to best accomplish this (McLean, Frisch, & Roudsari, 2015). Without involving nurses in this process, you would not know what issues need resolved and what the perceived problem is. Nurses can easily identify what needs improved. Involving nurses at this stage can help address problems that are not well known to everyone. Nurses from different specialties should be involved.
2. Design- Nurses typically make up a large portion of the people who will be implementing or carrying out the program and using it on a daily basis. Nurses who do not have input into design will sometimes find a system redundant or non- user friendly. This can lead to frustration and sometimes a delay in care if the system is hard to navigate for the nurse. Most of this phase is done by the IT team (Singletary & Baker, 2019). This would be a great stage to involve the nurse informaticist to bridge the gap between technology and nursing. The easier it is to navigate the system the better the outcomes for the nurses. Some programs are not well -designed leading to undue stress on the staff
3. Implementation-If nurses are not properly trained for implementation, they may be discouraged from using the program. If there are no resources for this stage the staff will fail to comply with the program. Nurses could potentially train as super-users for program implementation (Tyler, 2019). Nurses need to have a go to person for any questions about the program and how to overcome them.
4. Maintenance/Evaluation- If program developers and participants do not get the input from nurses about the pros and cons of the system, they may never truly make it a great program. Policies and procedures are always changing and there is a need to constantly evaluate the effectiveness of the system. Nurses should be allowed to be part of this process so that the program can be edited based on the needs of the nurses and the patients.
I have been involved in the implementation of the Cerner program at the hospital I formerly worked at. We switched to Cerner from a paper system, so it was quite the change and came with a lot of challenges. All staff were trained on the system and a select few had additional training to be super users. Those who did not receive additional training were not as well prepared and, in my opinion, all staff should have had the additional education. We also had cheat sheets made out for us with the most frequently asked questions/problems that we used for resources. It was a challenge to get everyone motivated to switch to an electronic health record from paper, but eventually we made the switch. We also had a nurse informaticist who was available for questions or when problems came up with the system. There were numerous times that the nursing staff voiced concern over an issue with the system being redundant or cumbersome, but the complaints never made a difference in editing the program. Our complaints were never taken any further up the chain.
References
McLean, A., Frisch, N., & Roudsari, A. (2015, December 19). Nursing’s voice in healthcare IT acquisition decisions. Retrieved from http://cjni.net/journal/?p=4248
Singletary, V., & Baker, E. L. (2019). Building informatics-savvy health departments. Journal of Public Health Management and Practice, 25(6), 610-611. doi:10.1097/phh.0000000000001086
Tyler, D. (2019). A day in the life of a nurse informaticist. Journal of Informatics Nursing, 4(1), 18-20. Retrieved from https://search.proquest.com/openview/6eb08f968194395ecb5e118039adfe49/1?pq-origsite=gscholar&cbl=2044826
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