Lab Assignment: Assessing the Genitalia and Rectum
Pediatric Nurse Practitioner, Walden University
NURS 6512 C, Section 9, Advanced Health Assessment
Lab Assignment: Assessing the Genitalia and Rectum
The case study we will review includes “T.S, “a 32-year-old female presenting with
dysuria, frequency, and urgency that started two days ago. We will review the episodic note
, provided and determine what information is missing within the subjective and objective portions.
The diagnostic tests will be reviewed, and we will recommend additional tests that should be
obtained. The Assessment portion will be examined, and we will decide if we agree with the
current diagnosis and provide additional differential diagnoses to consider.
Subjective Portion
Our patient in the case study has been experiencing dysuria, polyuria, and urgency when
urinating. She reports that she has not tried taking anything to help alleviate the discomfort. She
reports that she has had these symptoms in the past. She is reportedly sexually active with a new
partner starting approximately three months ago.
It would be important to ask if our patient self-identifies as a female, male, transgender
man or woman, and what was the sexual assignment at birth. I would want to know when our
patient’s last menstrual cycle was, how long she had menstruation during that cycle if she had
heavy bleeding, and if she experienced any cramping. I would also ask if she has had any
vaginal discharge in the past few weeks. Regarding her urinary symptoms, I would ask if her
symptoms were constant or intermittent and what the color of her urine is. It would be important
to know when her last Pap smear and sexually transmitted infection testing was completed, what
those results were, and if she has ever been diagnosed with a sexually transmitted infection. She
mentioned that she has experienced these symptoms in the past, so I would inquire what the
diagnosis was at that time and whether she completed the treatment as directed. (Dains,
Baumann, Scheibel, et al., 2019)
The subjective portion did not include her family, personal, or social history. I would
review her family history with her to see if that had the presence of diabetes, cancer of the
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