Assignment: Assessing the Genitalia and Rectum Case Study

Assignment: Assessing the Genitalia and Rectum Case Study

Assignment: Assessing the Genitalia and Rectum Case Study

GENITALIA ASSESSMENT
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.

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• 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, negMcBurney

Diagnostics: HSV specimen obtained
Assessment: Chancre

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.
• 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.
Please do not write the paper in soap note format. PLEASE ANSWER ONLY THE QUESTIONS. DO NOT REWRITE THE CASE STUDY. Title page and Reference page required ( APA format ).
Dr.Suresh

To Prepare
• Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
• Based on the Episodic note case study:
o Review this week’s Learning Resources, and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.
o Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
o Consider what history would be necessary to collect from the patient in the case study.
o Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
o Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

The Lab Assignment
Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.
• 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 Sample Of This Assignment Written By One Of Our Top-rated Writers

Case Study

Current epidemiological findings indicate that young women between the ages of 15 and 24 years are getting infected with sexually transmitted infections (STIs) at a higher rate. Despite the fact that they only account up 25% of the population, they have a significant impact. It has been found that this population of young people make up about half of all newly diagnosed STI cases in the country. An important contributory factor is the inability of the majority of these young people to access preventive healthcare services, especially health education. Concerns about confidentiality make this vulnerable group of young people hesitant to present themselves to healthcare providers and reveal personal information (Shannon & Klausner, 2018). The purpose of this paper is to give out the missing information about the patient in the presented SOAP note.

The Patient

The particular patient in this case is a 21-old female college student. She belongs to the above-mentioned vulnerable population category. She acknowledges that one of the key characteristics of this group is the proclivity to have several sexual partners. She claims she had several sexual partners throughout the previous year. She also admits to having had chlamydia, a sexually transmitted infection that was treated two years ago. She comes in with painless but tough swellings on her genital area, which she believes need to be treated.

Subjective Part

The additional information for patient AB that should be included in the SOAP note documentation involves the following items:

• The chief complaint
• The history of presenting illness (HPI)
• Family history and social history
• Past medical and surgical history
• History of allergy
• Current medications, and
• A review of systems or ROS.

Objective Part

The information that is missing and that is to be added in the presented SOAP note in the objective part includes the following:

• Constitutional assessment (this includes looking at the patient’s appearance, her walking style or gait, whether she is alert or not, how she is dressed and other parameters).
• Body mass index or BMI: There is information about her height and weight; but the body mass index or BMI is not yet calculated. The available data indicates that her BMI is 24.2 kg/m².
• For this patient, they only took a HSV specimen and no other diagnostic test. The test confirms if the patient’s lesion is as a result of having herpes genitalis (Hammer & McPhee, 2018; Sauerbrei, 2016).

Support or Otherwise for the Assessment

The diagnosis of a chancre does not appear to be supported by the provided subjective and objective information. This patient’s lesions are painless and raised. If it were a syphilitic chancre it would indeed be painless. However, a chancre is not usually swollen or bumpy.

The Diagnostics

The appropriate diagnostics for this patient to help arrive at the correct diagnosis include these here below:

1. Nucleic acid amplification test (NAAT): A sample from the sore and other parts of the genital area and rectum is taken and examined in the laboratory. The diagnosis for this patient would be lymphogranuloma venereum in the event that this diagnostic test was to find the presence of the organism Chlamydia trachomatis (Hammer & McPhee, 2018; Macpherson & Cameron, 2017).
2. Rapid plasma reagin test: This is a test that looks for the bacterium Treponema pallidum in serum. If positive for the organism, this would indicate that the young lady is suffering from syphilis (Ghanem et al., 2020).
3. Microscopy: This is accomplished through dermoscopy, which involves placing scrapings or a biopsy from the genital lesion under magnification. The finding of Donovan bodies from the swab of the lesion would show that the patient suffers from Donovanosis. If the lesions have a whole in their center then it would probably be molluscum contagiosum as the diagnosis (Meza-Romero et al., 2019; Hammer & McPhee, 2018; Macpherson & Cameron, 2017).

To Reject or to Accept the Current Diagnosis

A syphilitic chancre being the current diagnosis in the supplied SOAP note, I would not accept the diagnosis. The reason for this is that the lesions are elevated, as opposed to the clinical appearance of a syphilitic chancre. This would indicate that patient AB has syphilis. The information in the subjective and objective sections, on the other hand, does not appear to support this diagnosis. Even if it is not unpleasant, a syphilitic chancre is not frequently elevated as a “rough bump.” These facts lead to the rejection of the presented diagnosis. The most common diagnosis is molluscum contagiosum, which is characterized by elevated, hard, spherical, and painless lesions. This is more in line with the offered subjective and objective data (Meza-Romero et al., 2019; Hammer & McPhee, 2018). When looking at the subjective and objective data, it’s evident that molluscum contagiosum with elevated, painless, and bumpy lesions is the most likely diagnosis.

Differential Diagnosis

Taking the primary or provisional diagnosis as molluscum contagiosum as described above, the other three differential diagnoses are as follow:

1. Donovanosis (granuloma inguinale). Its distinguishing characteristic is that the genital lesions would bleed easily and are usually without pain (Hammer & McPhee, 2018; Macpherson & Cameron, 2017)
2. The chancre usually represents syphilis is as a rule usually painless and not raised (Hammer & McPhee, 2018; Ghanem et al., 2020)
3. Lymphogranuloma venereum (LGV). For this STI the lesions are usually ulcerated. However, this patient’s lesions show no evidence of ulceration (Hammer & McPhee, 2018; Macpherson & Cameron, 2017).

References

Ghanem, K.G., Ram, S., & Rice, P.A. (2020). The modern epidemic of syphilis. New England Journal of Medicine, 382(9), 845-854. https://doi.org/10.1056/NEJMra1901593

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education.

Macpherson, P.A., & Cameron, D.W. (2017). Lymphogranuloma venereum, chancroid and granuloma inguinale. Infectious Diseases, 585–591.e1. http://dx.doi.org/10.1016/b978-0-7020-6285-8.00064-2 

Meza-Romero, R., Navarrete-Dechent, C., & Downey, C. (2019).  Molluscum contagiosum: An update and review of new perspectives in etiology, diagnosis, and treatment. Clinical, Cosmetic, and Investigational Dermatology, 12(1), 373-381. http://dx.doi.org/10.2147/CCID.S187224

Sauerbrei, A. (2016). Herpes genitalis: Diagnosis, treatment and prevention. Geburtshilfe Frauenheilkd, 76(12), 1310–1317. https://doi.org/10.1055/s-0042-116494

Shannon, C.L. & Klausner, J.D. (2018). The growing epidemic of sexually transmitted infections in adolescents: A neglected population. Current Opinion in Pediatrics, 30(1), 137-143. http://dx.doi.org/10.1097/MOP.0000000000000578