Genitourinary problems are among the public health concerns globally. Nurses and other healthcare providers adopt evidence-based interventions that would optimize patient outcomes in the treatment of these conditions. Subjective and objective data help nurses to formulate diagnoses and treatment plans. Therefore, this essay examines TS’s case study. TS has presented to the hospital complaining of dysuria, urgency, and frequency for the last two days. The essay focuses on topics that include additional subjective and objective information that should be obtained from the patient, if subjective and objective data supports the assessment, appropriate diagnostics, accepting or rejecting the diagnosis, and differential diagnoses to be considered for the patient.
Additional subjective information should be obtained from TS. Firstly, information about the character of her urine should be obtained. This includes information such as the smell and color of the urine. Bloodstained urine could indicate bladder problems while urine with a strong smell could imply that TS has a urinary tract infection. The nurse should also ask for information about the presence or absence of abnormal vaginal discharge. For instance, yellow or purulent vaginal discharge would indicate sexually transmitted infections. The character of TS’s symptoms should also be obtained. This includes seeking information on the factors that precipitate or alleviate her urinary symptoms. She should be asked about any activity that worsens or relieves her symptoms (Kaur & Kaur, 2021). The nurse should also assess her current level of pain using the pain rating scale. Pain rating could indicate the severity of her condition.
The nurse should also ask TS about her sexual habits. This includes sexual preferences and the use of protection when engaging in sexual intercourse. The information would help the nurse rule out causes such as sexually transmitted infections. Additional sexual-related information that should be obtained includes the use of contraceptives, the last menstrual period, and menstrual cycle problems. The nurse should also obtain information about any history of recurrent urinary tract infections. This would help determine if she has chronic urinary tract infections. Similarly, information about the history of sexually transmitted infections should be obtained to rule them out in her case. Information about her partner’s history of sexually transmitted infections and testing should also be obtained to rule out a risk of STD transmission. Information about TS’s social history is also needed. This includes data about smoking, dietary practices, and alcohol use (Bono et al., 2024). The nurse should also rule out the potential of heredity of TS’s problem. Information about a family history of health problems such as kidney disease or symptoms that TS has should be obtained.
Additional objective information should be obtained in TS’s case to guide the development of an accurate diagnosis and treatment plan. Firstly, the nurse should provide information about TS’s general appearance. Information such as her overall grooming, weight changes, presence or absence of chills or fatigue should be included in the objective portion. Abdominal assessment should provide information about the presence or absence of organomegaly, or abnormal pulsations. The case study should also provide detailed information about urine description (Bono et al., 2024). This includes urine color, smell, and the presence or absence of pus or blood in the urine.
The nurse should also provide information about the assessment of the genitourinary system. Information such as the presence or absence of vaginal discharge, lesions, or trauma should be documented to rule out causes such as sexually transmitted infections and intimate partner violence. The nurse should also assess TS’s level of pain. She should use a pain rating scale to determine the severity of her pain and prioritize the treatment plan accordingly (Boon et al., 2021). Pain assessment should also include TS’s experiences of pain on abdominal palpation.
Subjective and objective information support TS’s assessment. Nurses obtain subjective information by asking patients questions that relate to their health problems and different body systems. The subjective data helps the nurse determine the severity of a health problem and its impact on the client’s health and overall well-being. TS’s case study has subjective information. They include her chief complaints, history of her presenting illness, surgical history, past medical history, medication use, allergies, and social history. Nurses obtain objective data from their patients by using methods such as inspection, palpation, auscultation, and percussion. The objective data validates subjective claims by the patient. The case study has objective information. They include TS’s vital signs, abdominal assessment, and diagnostics ordered.
Some diagnostic and laboratory investigations should be ordered in TS’s case study to guide develop an accurate diagnosis and treatment plan. Firstly, a urinalysis test should be performed to rule out urinary tract infections. A diagnosis of urinary tract infection will be made should her urine test reveal the presence of leucocytes and nitrites. The presence of proteins in urine will indicate cardiovascular problems such as hypertension while the presence of glucose would imply that TS has diabetes. The presence of ketones will indicate the possibility of dehydration. TS should also be tested for sexually transmitted infections. Blood tests, vaginal swabs, and urine samples should be taken to rule out sexually transmitted infections such as gonorrhea and chlamydia infections. An abdominal CT scan should also be performed to rule out causes such as kidney stones. MRI might also be needed to rule out kidney stones and other renal pathologies that could be associated with TS’s problems (Kaur & Kaur, 2021). Lastly, cervical screening for cervical cancer should be done. Cervical screening would also help rule out other causes such as vaginosis in TS’s case.
I would accept the current diagnosis. TS’s complaints align with those seen in patients with urinary tract infections and sexually transmitted infections. Often, patients with these conditions experience dysuria, urgency, frequency, and fever, which are present in TS’s case (Bono et al., 2024). Therefore, additional diagnostic and laboratory tests will help determine if TS is suffering from STDs or UTIs. TS’s history of engaging in unprotected sex with her new partner makes STDs among the probable diagnoses to be considered.
One of the differential diagnoses that should be considered for TS is perinephric abscess. Perinephric access is a condition that develops from the spread of infections from other regions of the genitourinary tract to the kidneys (Okafor & Onyeaso, 2024). The infections result in the development of abscesses. Patients experience symptoms that include fever, chills, nausea, vomiting, flank pain, and fatigue (Adams et al., 2020). Unlike urinary tract infections or STDs, patients with perinephric abscesses might not experience symptoms such as urinary frequency or dysuria.
The other differential diagnosis that should be considered for TS is urethral syndrome. Urethral syndrome is a genitourinary condition characterized by urinary frequency, urgency, suprapubic pain, and dysuria. It develops from any condition that causes urethral irritation and inflammation. The urethral syndrome can develop due to sexually transmitted infections, urinary tract infections, or the use of foods that irritate the urethra (Sell et al., 2021). A confirmed diagnosis of either UTI or STD might indicate its co-existence with urethral syndrome.
The last differential diagnosis that should be considered for TS is kidney stones. Kidney stones develop from crystal deposition in the kidneys. Factors such as dehydration, intake of diets rich in salt, and overweight or obesity predispose individuals to kidney stones. Patients experience symptoms such as severe, sharp back or flank pain, pain radiating to the groin or lower abdominal regions, and dysuria. Patients might also report passing red or brown urine, foul-smelling and cloudy urine, frequency, nausea and vomiting, chills, and fever (Thongprayoon et al., 2020; Wang et al., 2021). The absence of red or brown-colored urine and sharp pain show that kidney stones are not the cause of TS’s complaints.
Overall, additional subjective and objective information should be obtained in the case study. Subjective and objective data support the assessment. Additional diagnostics and laboratory investigations should be ordered to develop an accurate diagnosis and treatment plan. I accept the current diagnosis based on TS’s symptoms. The three differential diagnoses that should be considered in TS’s case study include kidney stones, urethral syndrome, and perinephric abscess.
Adams, M., Bouzigard, R., Al-Obaidi, M., & Zangeneh, T. T. (2020). Perinephric abscess in a renal transplant recipient due to Mycoplasma hominis: Case report and review of the literature. Transplant Infectious Disease, 22(5), e13308. https://doi.org/10.1111/tid.13308
Bono, M. J., Leslie, S. W., & Reygaert, W. C. (2024). Uncomplicated Urinary Tract Infections. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK470195/