WK10 NURS 6512 ASSIGN

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Assignment Week 10: Assessing the Genitalia and Rectum

Patient Initials: AB Age: 21 Gender: Female

SUBJECTIVE DATA:

Chief Complaint (CC): External bumps in genital area.

History of Present Illness (HPI): AB, a 21-year-old white female presents to the clinic today with the complaints of external bumps to her genital area for unknown time. The patient has noticed the painless but rough to touch bumps about a week ago. She is sexually active since she was 18-year-old and had sex with more than one sexual partner the past year. Her last pap smear exam was 3 years ago with normal exam results. However, she reports that she previously was infected with chlamydia about 2 years ago with completed treatment. She denies abnormal vaginal discharge. The patient did not treat the bumps prior to coming to the clinic today.

Medications: Symbicort 160/4.5mcg

Allergies: No Known Drug Allergies

Past Medical History (PMH): Asthma

Past Surgical History (PSH): N/A

Sexual/Reproductive History: positive for chlamydia once

Personal/Social History: Denies tobacco use. Occasional alcohol use. Lives with spouse and three children (1 girl and 2 boys) in a single-family home in a suburban area. Patient is currently unemployed but attends business online school.

Immunization History: N/A

Significant Family History: No family history of breast or cervical cancer. Father: HTN, Mother: HTN, GERD

Lifestyle: N/A

Review of Systems: Heart: RRR, no murmurs Lungs: CTA, chest wall symmetrical

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Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact with a healed episiotomy scar present. 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, neg McBurney Diagnostics: HSV specimen obtained

OBJECTIVE DATA:

Physical Exam: 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 with a healed episiotomy scar present. 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, neg McBurney Diagnostics: HSV specimen obtained

ASSESSMENT: Primary Diagnosis:

Syphilis: Chancre Differential Diagnoses:

Chlamydia, Human Papilloma Virus, Herpes Simplex Virus, Gonorrhea, Contact Dermatitis

Additional Subjective Information

The subjective information is missing any detailed information about the patient’s sexual

practices and current use of contraceptives which is imperative to assess risk factors for

certain sexual-transmitted diseases. Providers should also interview the patient on

potential allergies and irritants. More subjective information is also needed on the

patient’s lifestyle choices and sexual/reproductive history to get a clearer picture of the

patient’s medical history to avoid ordering unnecessary tests.

Additional Objective Information

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The objective data should contain details about the review of each body system in order

to appropriate diagnose a patient and to rule out potential differential diagnosis. It is

important to know a patient’s general health state, to assess the lymph nodes for

swelling, throat and mouth for any other sores and lesions. The provider should assess

the patient’s respiratory system more detailed since there is a history of asthma.

Healthcare providers should also assess the patients bowl and bladder habits for any

changes or symptoms.

Assessment Support

The objective and subjective assessment has supported the provider to make the

primary diagnosis. However, the provider should include a head-to-toe assessment and

gather more details on the patient’s sexual history and practices to rule out differential

diagnoses. Also, the provider should be more precise about the genital lesions including

information about the borders, color, and size.

Current Diagnosis and Differential Diagnoses

The current diagnosis of the patient scenario is chancre. Chancre is also known

as the medical condition of a painless lesion or sore commonly found in the genital

area. With the patient’s current symptoms, risk factors, and unsafe sexually practices

this diagnosis may be warranted. However, a healthcare professional will need more

details and diagnostics done to confirm the primary diagnosis.

Chlamydia: The patient has a history of chlamydia which raises the highest

suspicion for reinfection of chlamydia along with the risk factors of being 21 years old,

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having more than one sexual partner, and not using barrier methods of contraception

(Dains, Baumann & Scheibel, 2016). Chlamydia can be asymptomatic but vaginal

discharge or bleeding may be another indicator in the later stages of the disease

(Centers for Disease Control and Prevention, 2017). However, chlamydia is not

associated with genital lesions but a chlamydia infection with syphilis infection is

possible.

Human Papilloma Virus (HPV): Genital warts are very commonly caused by the

human papillomavirus. Patients usually have few symptoms unless lesions become

larger, patients may experience bleeding, discharge, itching, and pain (Dains, Baumann

& Scheibel, 2016).

Herpes simplex virus infection: Genital herpes is a common sexually transmitted

disease. Affected patients often do not experience any symptoms or very mild

symptoms. Herpes sores appear as one or more blisters on or around the genital,

rectum, or mouth which are often mistaken as ingrowing hair or pimples (Center for

Disease Control and Prevention, 2017).

Gonorrhea: Patients with this sexually-transmitted disease experience purulent

discharge, dysuria, and pain during urination, painful intercourse and/or abdominal pain

(Mayo Clinic, 2018). More detailed sexual history and symptoms must be detected in

the health interview to determine if the patient is at risk for this type of STD.

Contact Dermatitis: A genital rash is referred to a spread of lesions or bumps.

Symptoms may include sores, bumps, blister, and lesions, irritation or inflammation,

itching or burning, discharge genitals, and pelvic pain (Ball, Baumann & Scheibel,

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2016). Furthermore, allergic irritants such lubricants and condoms may cause to

develop genital lesions.

Diagnostic Testing

The case study reveals that only a Herpes Simplex Virus sample was obtained.

To confirm the primary diagnosis, healthcare providers must collect a syphilis serologic

blood test to confirm the presence of antibodies. The diagnostic of syphilis also includes

a detailed health assessment interview including the onset of the chancre and the

examination of the chancre. It is common in syphilis to experience painless ulcerations

in the anogenital area which typically appears 9 to 90 days after exposure (Epocrates,

2018). Gonorrhea is detected with a recommended (Epocrates, 2018). Nucleic acid

amplification test (NAAT) Since the sexual history reveals multiple sexual partners and

no barrier protection, healthcare providers may want to utilize a speculum exam of the

cervix and vagina while collecting a clinician vaginal and endocervical swab along with a

urine sample to detect gonorrhea. Genital herpes can be detected with an HSV test

which was already obtained. Furthermore, type-specific serologic testing may be the

best diagnostic approach to detect HSV (Epocrates, 2018). To confirm a human

papilloma virus infection provider will collect a pap smear sample and DNA test for

laboratory testing (Mayo Clinic, 2018). Acute genital dermatitis is manifested by itching,

genital redness, and burning sensation. Diagnosis is made by history, physical exam,

and patch testing to detect irritants and contact sensitivity such as reaction to latex

condoms (Ljubojević et al., 2009).

References

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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.

Center for Disease Control and Prevention. (2017). Chlamydia – CDC Fact Sheet.

Retrieved from https://www.cdc.gov/std/chlamydia/stdfact-chlamydia.htm

Centers for Disease Control and Prevention. (2017). Genital Herpes – CDC Fact Sheet.

Retrieved from https://www.cdc.gov/std/herpes/stdfact-herpes.htm

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.

Epocrates Online. (2018). Gonorrhea Infection – Diagnostic Approach. Retrieved from

https://online.epocrates.com/diseases/5131/Gonorrhea-infection/Diagnostic-

Approach

Epocrates Online. (2018). Chlamydia Infection – Diagnostic Approach. Retrieved from

https://online.epocrates.com/diseases/5231/Genital-tract-chlamydia-

infection/Diagnostic-Approach

Epocrates Online. (2018). Syphilis Infection – Diagnostic Approach. Retrieved from

https://online.epocrates.com/diseases/5031/Syphilis-infection/Diagnostic-

Approach

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Ljubojević, S., Lipozencić, J., Celić, D. & Turcić, P. (2009). Genital contact allergy. Acta

Dermatovenerol Croatia (ADC), 17 (4), 285-8. Retrieved from

https://www.ncbi.nlm.nih.gov/pubmed/20021983

Mayo Clinic. (2018). HPV Infection. Retrieved from

https://www.mayoclinic.org/diseases-conditions/hpv-infection/diagnosis-

treatment/drc-20351602

Mayo Clinic. (2018). Gonorrhea. Retrieved from https://www.mayoclinic.org/diseases-

conditions/gonorrhea/symptoms-causes/syc-20351774

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