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Report.docx1 Assessing The Genitalia and Rectum
2 Additional information that should be included in the documentation of subjective data
3 It is necessary to ask pertinent questions when interviewing a patient. Neither does the patient have any form of pain or if the pain radiates. Therefore, it is vital to inquire about these things like an advanced practice nurse to make the best diagnosis and subsequent actions to the patient. I would have asked more questions on the patient’s HPI (HISTORY OF PRESENT ILLINESS) and history for additional information to help determine my diagnosis and develop a treatment plan. Firstly, I would ask the patient the number of sexual encounters she has engaged with before the appearance of the bump (Ball et al., 2017). I would ask the number of times she has sex in a day, is it with different partners, and if they are male, female, or both (Díaz-Jaime et al., 2017). In addition, I will ask whether she has experienced any trauma, cutting, or a bruise from activities such as shaving. Also, I will ask whether the patient has undergone any surgery, treatment in the recent past or has applied creams, lotions, or soaps that could irritate. The patient's physical exam revealed a painless internal scar that has indurated with a 2” diameter (Luo, Xie & Xiao, 2020). 3 But we should also inquire whether the bumps have been changed in size, if it affected her sex life and if she has noticed any increase or decrease in bumps in the past week. Critical information that should have been included in this assessment is whether the patient has used contraceptives and what bumps could be due to these contraceptives.
2 Additional information that should be included in the documentation of objective data
The objective information is defined by collected diagnostic tests, laboratory results, physical examination results, general assessment, and vital signs (Miranda et al., 2018). Therefore,
4 3 to be consistent with the patient’s subjective symptoms, it is important to ask more questions related to the physical assessment of the external genitalia. 5 More examination details need to be added to support the already known positive results that the patient has external labia (Ball et al., 2017). 4 For example, additional information on swelling, excoriation, irritation, inflammation, color, and palpation of the labia. This information will help the provider rule out the presence or absence of Bartholin gland infection (Díaz-Jaime et al., 2017). 4 Also, during a physical exam, milking of the skene gland is required to evaluate the infection correctly. I would also examine internal symptoms such as fistulas or polyps because the patients tested positive for the external labia. Considering infections that affect the vagina bypass quickly to the anus and vice versa, it would be essential to inspect and palpate the perineum (the full inspections of the rectum and anus). Since these sensitive areas are also easily infected with infections, it would be important to carry lymph and neurological tests. Lastly, a proper skin body and throat examination are also required to assess for other proximity signs.
2 Whether the subjective and objective information supports the assessment
I feel that the presented subjective and objective information presented by the patient and provider does support the diagnosis of the chancre. Upon the initial exposure to syphilis, chancre develops as painless indurative ulcers. According to Luo, Xie & Xiao (2020), a chancer is a painless ulcerative lesion that develops around the genitals, either internally or externally. The disease is transmitted when open sores contact an unaffected person with incubation of 1-5 weeks (Miranda et al., 2018).
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1 Most appropriate diagnostic tests for this case and how results would be used in making a diagnosis Possible diagnoses for this case would be narrowed down to one or two diagnoses using more diagnostic tests. 6 For example, it would be necessary to use Venereal disease research laboratory (VDRL), Treponema pallidum test (T. Pallidum), and Rapid plasma regain (RPR) to test for syphilis antibodies besides using the HSV specimen collected (Luo, Xie & Xiao, 2020). The disease’s stage in case it is present should be confirmed by other specific tests. 7 Following the patient’s history of STDs and being sexually active with several partners, it is essential to conduct chlamydia, gonorrhea, and HIV testing tests. 4 Negative STD results would require more testing of the bump (Ball et al., 2017). 8 If STD results were negative, it would be advisable to conduct a biopsy to test HPV and help rule out vulva cancer.
2 Whether I would accept/reject the current diagnosis
9 Based on the provided information on the subjective and objective data, I would accept the possible diagnosis of chancre or syphilis. 10 According to Díaz-Jaime et al. 7 (2017), syphilis symptoms present with non-tender bilateral lymphadenopathy, solitary, and painless indurated ulcers (chancre). 6 People who engage in high-risk sexual behavior should be suspected because the diagnosis is transmitted through unprotected sex, especially with the infected person (Ball et al., 2017). If the condition is not detected early and treated, it can lead to devastating effects like damage to the hepatic, musculoskeletal, and neurological systems (Miranda et al., 2018).
Possible differential diagnoses
5 Chancre or Syphilis Infection – this is a possible diagnosis because the patient could be developing painless indurated ulcer. She is engaging in non-protected sex which increases the chances of infection because it is transmitted sexually.
Genital herpes – another possible diagnosis because the client is meeting many partners who could be infected. To rule out the diagnosis, the client should be tested with HSV and HVC.
Bartholin Cyst – based on the subjective and objective data, the client may have this possible diagnosis because the disease is characterized with cysts formation in the glands that are painless unless they become infected and form an abscess (Ball et al., 2017). Since she is a young woman, it is likely to have Bartholin cyst.
Vulva cancer – though this disease is rare, it could be a possible diagnosis because it manifests with a painless lump on the vulva which may be accompanied with pruritis from vaginal irritation (Luo, Xie & Xiao, 2020). The client needs to undergo a vulva biopsy for definitive diagnosis confirmation.
11 Conclusion Genital and rectal complaints can be a sensitive topic for patients. 3 It is important that as an advanced practitioner, that we provide accurate subjective and objective examinations. In this case study we must treat our patient and coincidentally potentially two others based on her diagnosis.
6 References
Ball, J. 12 W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2017). 1 Seidel's Guide to Physical Examination-E-Book: 2 An Interprofessional Approach. 1 Elsevier Health Sciences.
13 Díaz-Jaime, F., Satorres-Paniagua, C., & Bustamante-Balén, M. (2017). 10 Primary chancre in the rectum: an underdiagnosed cause of rectal ulcer. Revista Española de Enfermedades Digestivas, 109(3), 236-237.
14 Luo, Y., Xie, Y., & Xiao, Y. (2020). 14 Laboratory Diagnostic tools for syphilis: current status and future prospects. Frontiers in Cellular and Infection Microbiology, 10.
Miranda, M. V. D., Rewa, T., Leonello, V. M., & Oliveira, M. A. D. C. (2018). Advanced practice nursing: a possibility for Primary Health Care? Revista brasileira de enfermagem, 71, 716-721.
