Assignment Week 10 Assessing The Genitalia And Rectumpatient Initials ✓ Solved

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 © 2014 Laureate Education, Inc. Page 1 of 7 This study source was downloaded by from CourseHero.com on :29:39 GMT -05:00 Th is stu dy re so ur ce w as sh ar ed v ia C ou rs eH er o. co m 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 5’10â€; 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 © 2014 Laureate Education, Inc. Page 2 of 7 This study source was downloaded by from CourseHero.com on :29:39 GMT -05:00 Th is stu dy re so ur ce w as sh ar ed v ia C ou rs eH er o. co m 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, © 2014 Laureate Education, Inc.

Page 3 of 7 This study source was downloaded by from CourseHero.com on :29:39 GMT -05:00 Th is stu dy re so ur ce w as sh ar ed v ia C ou rs eH er o. co m 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, © 2014 Laureate Education, Inc. Page 4 of 7 This study source was downloaded by from CourseHero.com on :29:39 GMT -05:00 Th is stu dy re so ur ce w as sh ar ed v ia C ou rs eH er o. co m 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 © 2014 Laureate Education, Inc. Page 5 of 7 This study source was downloaded by from CourseHero.com on :29:39 GMT -05:00 Th is stu dy re so ur ce w as sh ar ed v ia C ou rs eH er o. co m 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 Centers for Disease Control and Prevention. (2017). Genital Herpes – CDC Fact Sheet. Retrieved from 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 Approach Epocrates Online. (2018). Chlamydia Infection – Diagnostic Approach. Retrieved from infection/Diagnostic-Approach Epocrates Online. (2018).

Syphilis Infection – Diagnostic Approach. Retrieved from Approach © 2014 Laureate Education, Inc. Page 6 of 7 This study source was downloaded by from CourseHero.com on :29:39 GMT -05:00 Th is stu dy re so ur ce w as sh ar ed v ia C ou rs eH er o. co m Ljubojević, S., Lipozencić, J., Celić, D. & Turcić, P. (2009). Genital contact allergy. Acta Dermatovenerol Croatia (ADC), 17 (4), 285-8.

Retrieved from Mayo Clinic. (2018). HPV Infection. Retrieved from treatment/drc- Mayo Clinic. (2018). Gonorrhea. Retrieved from conditions/gonorrhea/symptoms-causes/syc- © 2014 Laureate Education, Inc. Page 7 of 7 This study source was downloaded by from CourseHero.com on :29:39 GMT -05:00 Th is stu dy re so ur ce w as sh ar ed v ia C ou rs eH er o. co m Powered by TCPDF (

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Assignment Week 10: Assessing the Genitalia and Rectum - Case Study Analysis
Patient Initials: AB
Age: 21
Gender: Female
Patient Presentation
AB, a 21-year-old Caucasian female, presents with external bumps in her genital area that she has noted for the past week. These bumps are painless and have a rough texture. She has been sexually active since she was 18 and reports having multiple partners in the last year. Her medical history shows a prior chlamydia infection treated two years ago. AB has not experienced abnormal vaginal discharge and has not sought treatment for the bumps. Her last pap smear was three years ago with normal results.
Subjective Data Analysis
In gathering subjective data, it is crucial to explore AB's sexual history comprehensively. This includes specifics regarding her sexual partners, contraceptive usage, and any preventive measures taken to mitigate sexually transmitted infections (STIs). Given AB's history of chlamydia and the report of painless bumps, there is reason to suspect a recurrent STIs, particularly with the high-risk behavior indicated by multiple partners (Dains et al., 2016).
AB's report of painless bumps aligns with typical presentations of conditions such as genital warts (HPV) or the initial stages of syphilis (chancre), both of which require thorough exploration and appropriate follow-ups. Furthermore, it is beneficial to investigate lifestyle factors, including any changes in personal care products that could induce irritant contact dermatitis, leading to similar presentations (Ball et al., 2015).
Other significant points in her history include the absence of tobacco use and occasional alcohol consumption. The family medical history indicates hypertension but lacks information on significant gynecological conditions.
Objective Data Analysis
The physical examination indicated that the genital area has normal hair distribution and intact urethral structures with a notable painless ulcerative lesion on the external labia. This may suggest syphilitic chancre, which typically appears as a painless ulcer in the early stage of the infection (Epocrates, 2018). However, the remaining normal findings must also be considered, indicating the possibility of other dermatological or infectious processes.
Objective assessments, along with vital signs appearing within normal limits, allowed for a thorough initial evaluation. This would ideally be complemented by broader assessments of lymph node involvement, general skin health, and possibly oral examinations to rule out systemic symptoms related to STIs.
Assessment of Current and Differential Diagnoses
Given AB's clinical presentation and subjective history, the primary consideration is a diagnosis of syphilis, specifically the presence of a chancre. Nevertheless, differential diagnoses must be rigorously explored, especially considering her previous chlamydia infection. Key differential diagnoses include:
1. Chlamydia: Recurrences are common in sexually active individuals, and given her history, further testing is warranted (CDC, 2017).
2. HPV: Often manifests as external warts that can be mistaken for other lesions if not carefully differentiated (Dains et al., 2016).
3. Herpes Simplex Virus (HSV): Typically presents as painful vesicular lesions; however, painless ulcers can also occur (CDC, 2017).
4. Gonorrhea: This may manifest with purulent discharges or systemic signs that need assessment through a targeted interview (Mayo Clinic, 2018).
5. Contact Dermatitis: Allergic reactions can result in lesions that mimic infection, necessitating an inquiry into new products or irritants (Ljubojević et al., 2009).
Diagnostic Testing
In this case, HSV specimen testing has already been initiated, which aids in ruling out genital herpes. To confirm the diagnosis of syphilis, serological tests for Treponema pallidum are critical in identifying past or current infections (Epocrates, 2018).
Additional tests for chlamydia and gonorrhea utilizing nucleic acid amplification tests (NAATs) should also be performed due to the risk factors documented in AB's sexual history. Furthermore, a Pap test with HPV typing can provide valuable insights (Mayo Clinic, 2020).
Conclusion and Recommendations
This detailed patient assessment emphasizes the need for thorough sexual health evaluations and targeted diagnostic tests in managing patients who present with genital lesions.
Healthcare providers must gather detailed sexual histories and be prepared to educate patients on safe sexual practices and the importance of regular screenings for sexually active individuals (CDC, 2017).
AB should be informed about the implications of her conditions, treatment options for potential STIs, and the importance of regular follow-up appointments, particularly due to her history and active lifestyle. Additionally, reassurance and education regarding the management of STIs could significantly enhance her engagement in future healthcare decisions.
References
1. 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.
2. Centers for Disease Control and Prevention. (2017). Chlamydia – CDC Fact Sheet. Retrieved from https://www.cdc.gov/std/chlamydia
3. Centers for Disease Control and Prevention. (2017). Genital Herpes – CDC Fact Sheet. Retrieved from https://www.cdc.gov/std/herpes
4. 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.
5. Epocrates Online. (2018). Gonorrhea Infection – Diagnostic Approach. Retrieved from https://www.epocrates.com
6. Epocrates Online. (2018). Chlamydia Infection – Diagnostic Approach. Retrieved from https://www.epocrates.com
7. Epocrates Online. (2018). Syphilis Infection – Diagnostic Approach. Retrieved from https://www.epocrates.com
8. Ljubojević, S., Lipozenčić, J., Čelić, D., & Turčić, P. (2009). Genital contact allergy. Acta Dermatovenerol Croatia (ADC), 17(4), 285-8.
9. Mayo Clinic. (2018). HPV Infection. Retrieved from https://www.mayoclinic.org
10. Mayo Clinic. (2018). Gonorrhea. Retrieved from https://www.mayoclinic.org
This comprehensive evaluation provides insights into the diagnosis and management of sexually transmitted conditions while underlining the importance of informed patient care and education in primary practice settings.