Comprehensive history taking and physical examination skills are important during patient assessment for accurate diagnosis. This paper explains how to obtain a detailed history from patients and how to examine the genitalia and rectum of a male patient. It then gives the probable diagnoses based on the symptoms present.
History Taking in Dysuria
When assessing an illness, the APN finds out the presence and duration of symptoms such as fever, the pain of the flank and suprapubic, and urethral discharges. The APN also looks for a history of trauma, symptoms of obstruction such as dribbling as well as an increase in the frequency and urgency to pass urine. The APN inquires for any urine changes like the presence of blood, smell, color changes, discharge characteristics such as thickness, quantity and smell. History of unsafe sex, application of probable irritating substances to the perineum and recent catheterization history are also vital (Bickley & Szilagyi, 2014). Past medical history of urinary infections, abnormalities of the urinary tract and kidney stone disease are also vital (Porter & Kaplan, 2011).
Examination of the Rectum and Male Genitalia
The first step in the examination of male genitalia is observation for swellings and scars. The APN then examines the groin for hernias, penile and scrotal abnormalities. The APN also examines the glans penis and prepuce in uncircumcised patients as well as the urethra for epispadia and hypospadia. The next step is palpation of the testes to determine their presence, the existence of masses and swellings, especially in hydrocele and orchitis. Palpation also reveals any tenderness of the epididymis and testes (Bickley & Szilagyi, 2014).
The rectal examination comes after genital examination with the patient lying in the left lateral position. The APN inspects for bleeding, skin changes and hemorrhoids. A digital rectum examination (DRE) enables the APN to assess the prostate lobes, rectal tone and rectal masses. Pain on palpation often suggests an infection.
The APN may perform a DRE on the patient, which is vital in the diagnosis of prostate enlargement when there are changes in urination and rectal abnormalities. Urinalysis and urine culture tests for possible urinary tract infections (UTIs) are usually helpful in identifying hematuria and bacteria in the urine. Leukocyte esterase in urinalysis is accurate in the detection of UTIs (Ball, Dains, Flynn, Solomon, & Stewart, 2015).
Prostate-specific antigen (PSA) levels are reasonably high in patients with benign prostate hypertrophy (BPH). PSA elevations in prostate cancer depend on the tumor size and require further evaluations like transrectal biopsy. Uroflowmetry, which is a vital test in determining urethral blockages and bladder muscle weakness, measures the amount and speed of urination. Performing a transrectal biopsy is crucial in the diagnosis of prostate cancer by collecting tissues for histology.
The first probable diagnosis is urethritis, which often presents with dysuria and urethral discharge mainly in males. The discharge is usually purulent in N. gonorrhea infection (Mayo Clinic, 2014).
Cystitis presents with frequent, urgent and painful emptying of the urine. The condition also presents with suprapubic and low back pain as its primary symptoms. A low-grade fever may develop later (Mayo Clinic, 2014).
The dysuria in the patient is likely to be because of urethral strictures. This situation often arises due to trauma of the urethra during intercourse or sensitivity reactions to creams and soap.
The fourth differential diagnosis is prostatitis, which is among disorders that manifest with irritation, obstructive urinary symptoms and perineal pain. The non-bacterial prostatitis subtype is common in patients with chronic prostatitis.
The fifth probable diagnosis is bladder cancer which usually presents with hematuria and urinary obstruction that causes pain (Ball et al., 2015). This condition is common in patients with exposure to hydrocarbons and industrial chemicals.
Lower urinary tract symptoms (LUTS) have a number of causes that require the APN to examine the symptoms carefully to determine the underlying causes. Non-infective causes like BPH require frequent monitoring to get baseline values that guide future diagnoses.
Knowing a patient’s history as well as understanding the implications of the symptoms present is important in coming up with the correct diagnosis. From case 2, it is clear that the patient experiences frequent painful urination. It is also apparent that the patient does not have multiple sexual partners. This information is, therefore, vital in coming up with the actual diagnosis from the list of possible complications.
The patient’s diagnosis is not urethritis because he does not exhibit symptoms of inflammation. Other signs of the condition are aches, dysuria, irritation, repeated urination, problems in initiating urination, and painful intercourse (Ball et al., 2015). These symptoms are absent in the patient thereby ruling out a diagnosis of urethritis (Mayo Clinic, 2014).
Another unlikely diagnosis is cystitis, which is the inflammation of the bladder. Probable causes of the condition are gonococcal bacterial infections after unprotected sex, urethral damage after trauma and incomplete voiding of the bladder in obstructive disorders. The patient, in this case, does not show signs of kidney inflammation like fever hence ruling out kidney infection. The patient also reports having one sexual partner, which excludes the possibility of venereal infections.
The condition is unlikely to be kidney stones, which manifest with extreme flank and back pains. The probable diagnosis for the patient is benign prostate hypertrophy (BPH), which is the enlargement of the prostate due to his age and a positive family history of BPH (American Cancer Society, 2014). Confirmation of the diagnosis is through digital rectal examination of the prostate gland and determining the current serum PSA levels (Prostate Cancer Foundation, 2014).
American Cancer Society. (2014). Prostate cancer early detection. Web.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. Web.
Bickley, L., & Szilagyi, G. (2014). Bates’ guide to physical examination and history-taking (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Web.
Mayo Clinic. (2014). Painful urination. Web.
Porter, R. S. & Kaplan, J. L. (2011). The Merck manual of diagnosis and therapy (19th ed.). White Station, NJ: Merck Sharp & Dohme Corp. Web.
Prostate Cancer Foundation. (2014). Prostate cancer research. Web.