Assignment: Lab Assignment: Assessing the Genitalia and Rectum

Subjective:

·

CC:

“I

have

bumps

on

my

bottom

that

I

want

to

have

checked

out.”

·

HPI:

AB,

a

21

-

year

-

o

ld

WF

college

student

reports

to

your

clinic

with

external

bumps

on

her

genital

area.

She

states

the

bumps

are

painless

and

feel

rough.

She

states

she

is

sexually

active

and

has

had

more

than

one

partner

during

the

past

year.

Her

initial

sexual

contact

occ

urred

at

age

18.

She

reports

no

abnormal

vaginal

discharge.

She

is

unsure

how

long

the

bumps

have

been

there

but

noticed

them

about

a

week

ago.

Her

last

Pap

smear

exam

was

3

years

ago,

and

no

dysplasia

was

found;

the

exam

results

were

normal.

She

reports

o

ne

sexually

transmitted

infection

(chlamydia)

about

2

years

ago.

She

completed

the

treatment

for

chlamydia

as

prescribed.

·

PMH:

Asthma

·

Medications:

Symbicort

160/4.5mcg

·

Allergies:

NKDA

·

FH:

No

hx

of

breast

or

cervical

cancer,

Father

hx

HTN,

Mother

hx

HTN,

GE

RD

·

Social:

Denies

tobacco

use;

occasional

etoh,

married,

3

children

(1

girl,

2

boys)

Objective:

·

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.

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:

·

Chancre

·

Analyze the subjective portion of the note. List additional information that should be included

in the documentation.

·

Analyze the objective portion of the note. List additional information that should be included

in the documentation.

·

Is the assess

ment supported by the subjective and objective information? Why or why not?

·

Would diagnostics be appropriate for this case, and how would the results be used to make a

diagnosis?

·

Would you reject/accept the current diagnosis? Why or why not? Identi

fy three possible

conditions that may be considered as a differential diagnosis for this patient. Explain your

reasoning

using at least three different references from current evidence

-

based literature.

.

A clear and comprehensive purpose statement, introduction, and conclusion are provided that

delineate all required criteria.

Subjective:

 CC: “I have bumps on my bottom that I want to have checked out.”

 HPI: AB, a 21-year-old WF college student reports to your clinic with external

bumps on her genital area. She states the bumps are painless and feel rough. She

states she is sexually active and has had more than one partner during the past year.

Her initial sexual contact occurred at age 18. She reports no abnormal vaginal

discharge. She is unsure how long the bumps have been there but noticed them

about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was

found; the exam results were normal. She reports one sexually transmitted infection

(chlamydia) about 2 years ago. She completed the treatment for chlamydia as

prescribed.

 PMH: Asthma

 Medications: Symbicort 160/4.5mcg

 Allergies: NKDA

 FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD

 Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:

 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. 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:

 Chancre

 Analyze the subjective portion of the note. List additional information that should be included

in the documentation.

 Analyze the objective portion of the note. List additional information that should be included

in the documentation.

 Is the assessment supported by the subjective and objective information? Why or why not?

 Would diagnostics be appropriate for this case, and how would the results be used to make a

diagnosis?

 Would you reject/accept the current diagnosis? Why or why not? Identify three possible

conditions that may be considered as a differential diagnosis for this patient. Explain your

reasoning using at least three different references from current evidence-based literature.

. A clear and comprehensive purpose statement, introduction, and conclusion are provided that

delineate all required criteria.