Assessing the Genitalia and Rectum

Assessing the Genitalia and Rectum
Paper details:

Case 2: Dysuria

A 55-year-old African-American male reports to your clinic complaining of frequent and painful urination for the past 2 months. The patient is sexually active and has been in a monogamous relationship for the past 3 years. He reports no penile discharge, fever, chills, abdominal pain, or back pain. His father is deceased and passed away of colon cancer. His father had a history of benign prostatic hypertrophy (BPH). The patient considers himself as a healthy male. He works for a large American corporation, has a relatively healthy diet, and exercises 4 to 5 times per week . please the following format example of what paper should look like you will have to make up stuff .
Review of Case Study #1 – Lower Back Pain Attachment

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NURS 6512 Week 8 – COMPREHENSIVE SOAP NOTE – CASE STUDY #1

PATIENT NAME: A.A. AGE: 42 GENDER: Male

CHIEF COMPLAINT (CC): “I have been experiencing pain in my lower back since last month”

HISTORY OF PRESENT ILLNESS (HPI): Mr. A is a 42-year African American male presenting to the clinic with lower back that started last month. The patients was doing yard work about 5 weeks ago and started feeling pains in his lower back about 1 week later. The pain is sharp at times but mostly he feels a dull, throbbing, and burning pain down his entire left leg. He has not been able to work for the last week because his job entails stocking shelves with aggravates his back pain. Pt. is not comfortable sitting or standing. Laying down with legs elevated under pillows seen to help with the discomfort as well as soaks in his bathtub nightly. Pt. started taking 400mg of Motrin 3 times a day. He rates his pain at a 7/10 today.

PAST MEDICAL HISTORY (PMH):

Medical:

1. GERD

2. Eczema

Surgical:

1. None

Medications:

1. Tums – OTC

Allergies: NKDA

Health Maintenance: Last physical exam was 3 years ago. Last dental visit was 1.5 years ago – pt. normally goes once a year

Immunizations: Pt. does not get vaccinations

FAMILY HISTORY: Family history unknown – patient was adopted. No sisters or brother and no children

PSYCHOSOCIAL HISTORY: Single, no children, lives alone. Denies smoking and drugs, but drinks beers on the weekends. Pt. eats a lot of fast food but makes sure he gets adequate fruits and vegetables.

REVIEW OF SYSTEMS:

General: Denies fever, chills, night sweats. Positive for lack of sleep due to lack of comfort. Weakness in lower left leg.

HEENT: Denies vision and hearing changes, headaches, sore throat, or nasal discharge or stuffiness

Neck: Denies neck stiffness or nodules. Denies trouble swallowing

Testes: Denies lumps, bumps or inflammation on testicles

Respiratory: Denies SOB and cough

Cardiovascular: Denies check pain or swelling

Gastrointestinal: Denies n/v, abdominal pain, constipation or diarrhea. Positive for occasional heartburn

Genitourinary: Denies urgency or frequency with urination. Denies burning, itching or blood in the urine

Musculoskeletal: Denies full ROM in BLE. Positive for stiffness, pain, and aches in lower back and left leg. Reports muscles weakness in back

Psychological: Denies mood changes, agitation, suicidal thoughts, or depression.

Neurological: Denies dizziness, memory loss, or seizures.

Integumentary/Hematologic/Lymphatic: Denies bruises, lumps, bumps, or nodules. Denies swelling or tenderness under arm pits, neck, or groin

Endocrine: Denies excessive thirst or urination. Denies thyroid problems

Allergic/Immunologic: No allergy or recurrent infections

PHYSICAL EXAM:

Vital Signs: BP-174/92; P-102; RR-20; T-98.6, pulse ox 100%; Wt.-230 lbs.; Ht.-6’2

General: Patients appears well-developed, alert and oriented.

Skin: Skin intact

HEENT: WNL

Cardiovascular: WNL

Musculoskeletal: Decreased ROM in the spine, especially with forward and side flexion. Negative for SLR, leg extension at the knee, heel walking or squatting

Abdomen: WNL

Rectal: WNL

Neurological: symmetrical DTRs, Negative for numbness or tingling

ASSESSMENT:
1.Lower back pain that extends down the left leg. Most likely musculoskeletal strain, R/O differential diagnosis

Differential Diagnosis (DDx):
1.Sciatica
2.Herniated Disk
3.Spinal Fracture
4.Spinal stenosis
5.Tumor

Diagnosis/Patient Problem: Musculoskeletal strain is the most likely diagnosis. Musculoskeletal strain is an injury to the muscle as a result of stretching or tearing of muscle fibers beyond the normal limits (“Musculoskeletal Strains and Sprains”, 2015). Overuse and strain on the back muscles and ligaments can cause inflammation. Patients report that pain can be alleviated by rest, heat, and cold and aggravated with certain range of motion, walking, sitting or standing. Palpating around the spinal column can usually localize the pain, and range of motion in that particular area will increase the pain but no neurological deficits will be noted (Dains, Baumann, & Scheibel, 2016).

R/O: Sciatica – Acute back pain with radiculopathy that is relieved with sitting. Positive for sitting knee extension. EMG test if problem is chronic.

Herniated Disk – Lower back pain that radiates to the buttock and below the knee that presents for less than a month. Positive for SLR. No diagnostic study.

Spinal Fracture – Trauma to the back and spine with palpable tenderness over the fracture site. A spinal fracture is seen as an emergency so the patients should be immobilized and x-rayed.

Spinal Stenosis – Pain gets worse throughout the day which is aggravated by standing but relieved with rest. Presents with possible neurological symptoms and signs of osteoarthritis of the joints. No diagnostic study.

Tumor – History of cancer with progressive pain that occurs at night and at rest. Weight loss, fever, and tenderness near tumor. ESR and bone scan test (Dains, Baumann, & Scheibel, 2016).

PLAN:
1.Collect a focused history asking various questions to include information about fever, trauma, systemic diseases, age, bowel and bladder issues, long term medications, location of pain, onset and duration of pain, pain characteristics, factors that aggravate and alleviate the pain, radiation of pain, stumbling when walking, numbness or weakness, family history, and any illnesses.
2.Perform a physical assessment to include general appearance and behavior, gait, vital signs, skin, ears, eyes, nose, mouth, back and extremities, percuss and palpate back and spine, perform range of motion of the spine and straight leg raising, check hip mobility, examine feet, evaluate muscle strength, measurement for muscle circumference, Test sensory function, assess deep tendon reflexes, palpate abdomen, and check rectal sphincter.
3.No diagnostic test would be performed because the patient did not have any neurological deficits.
4.Educate the patient on ways to reduce low back pain by using the appropriate techniques to lift heavy objects. Give handouts with specifics techniques to use and what to avoid.

References

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

Musculoskeletal Strains and Sprains – Guidelines for Prescribing NSAIDs. (2015). Retrieved

From http://medsask.usask.ca/professional/guidelines/musculoskeletal-strains-and-

sprains.php

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