Assessing the Genitalia and Rectum Essay Assignment

Assessing the Genitalia and Rectum Essay Assignment

Assessing the Genitalia and Rectum Essay Assignment

Genitalia Assessment And Rectum Sample

The provided case study is about Ms. AB, a 21-year-old white female college student. AB reports to the clinic with a complaint of bumps on her genital area. The documentation shows subjective, objective, and assessment data for AB. The purpose of this lab assignment is to suggest additional subjective prompts, expected objective findings, appropriateness of the listed possible diagnoses, and appropriate diagnostics to be ordered.

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Additional Subjective Information

The subjective information elaborates on the presenting illness and some risk factors for genitourinary diseases. The following questions will help me gain more subjective information about Ms. AB regarding her reproductive health risk. 

• Do you have similar bumps somewhere else in your body? Is this the first time you are having these bumps? These questions will attempt to assess if this is a localized or generalized disease and establish if this is a recurrent disease (Ball et al., 2018).
• Do you use protection when having relations with your partners? In this question, I will inquire about the risk of sexually transmitted infections. The type of sexual intercourse such as anal, oral, and vaginal should be inquired from this patient.
• Do you have pain in your lower abdomen? Do experience pain when having sexual intercourse? These two questions are to rule out pelvic inflammatory disease owing to the young age of the patient and her multiple partners.
• Alongside Symbicort, do use any other medications, over the counter or prescribed? In this question, I would want to rule out medications as a possible cause of her bumps.

Additional Objective Information

Examination of the rectum and anal region would be necessary for this patient. In cases of nonvaginal intercourse leading to STIs, lesions can be found in other regions. The oral examination would also rule out inoculation in the mouth and throat. The number, size, and location of the ulcer would also be reported in additional genital examinations (Leblond et al., 2020). This is important to rule out other causes such as trauma and malignancies. Cervical motion tenderness would also be examined in this patient to rule out the involvement of internal reproductive organs.

Relevance of the Assessment

Regarding the provided history and physical findings, I would accept chancre as a provisional diagnosis. However, specifying painless chancre would be more specific to this patient. Using the provided information, there still exists room for other diagnoses such as syphilis, genital herpes, chancroid, Behcet’s disease, fixed drug eruption, sexual trauma, and genital psoriasis. Syphilis is the primary diagnosis in this patient because of her multiple sexual partners and painless chancre (Maliyar et al., 2019). Because of the limited information provided, Behcet’s disease, a disease that presents with oral and genital ulcers, can be a possible option because of genital ulcers. Fixed drug eruptions can occur anywhere in the body and the genital area is not an exclusion (Jhaj et al., 2018). Sexual trauma would have caused trauma to the genital area this need to be ruled out in the history and patterns of genital ulcers on physical examination. The absence of pain makes this differential diagnosis less likely. Chancroid, a sexually transmitted infection caused by a bacteria called Hemophilus ducreyi, is rare but causes genital ulcers. However, its ulcers are often painful. Genital psoriasis is a skin condition that is not caused by infectious agents but does not also spare the genital area. Ulcerations in genital psoriasis can be found elsewhere in the body (Roett, 2020). Genital herpes, caused by the herpes simplex virus, causes painful sores or ulcers as opposed to this patient’s ulcer. However, it should be ruled out in this patient because it is a common sexually transmitted disease in both men and women.

Appropriate Diagnostics

HSV specimen for polymerase chain reaction tests (PCR) to rule out genital herpes is an important diogenitic in this patient. Venereal disease research lab (VDRL) tests to rule out syphilis would also be useful. Treponemal tests such as TP-PA for syphilis would be an initial test to order (Roett, 2020). Genital syphilis is at the top of my differential list per the provided information about the patient. An early diagnosis to prevent the progression to secondary and tertiary disease would be a good preventive step. Nevertheless, the role of further history and physical examination is critical in ruling out many differentials and focusing diagnostics for this patient.

Conclusion

Ms. AB’s provided information is insufficient to make a final impression of a specific diagnosis and treatment. Additional history would assess her sexual practices, genital trauma, abdominal pain systemic disease, and recurrent disease. I would also examine the mouth to rule out similar bumps. The primary disease for Ms. AB was syphilis but other diagnoses such as genital herpes, chancroid, Behcet’s disease, fixed drug eruption, sexual trauma, and genital psoriasis could also be possible. Therefore, additional tests such as TP-PA and PCR for HSV will rule in or out syphilis and genital herpes respectively. The other diagnoses would be ruled out on additional history and physical examination findings that would further prompt additional tests.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2018). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). Mosby.

Jhaj, R., Chaudhary, D., Asati, D., & Sadasivam, B. (2018). Fixed-drug Eruptions: What can we Learn from a Case Series? Indian Journal of Dermatology, 63(4), 332–337. https://doi.org/10.4103/ijd.IJD_481_17

Leblond, R. F., Brown, D. D., & Suneja, M. (2020). Degowin’s Diagnostic Examination, 11th Edition (11th ed.). McGraw-Hill Education/Medical.

Maliyar, K., Mufti, A., Syed, M., Selk, A., Dutil, M., Bunce, P. E., & Alavi, A. (2019). Genital ulcer disease: A review of pathogenesis and clinical features. Journal of Cutaneous Medicine and Surgery, 23(6), 624–634. https://doi.org/10.1177/1203475419858955

Roett, M. A. (2020). Genital ulcers: Differential diagnosis and management. American Family Physician, 101(6), 355–361. https://www.ncbi.nlm.nih.gov/pubmed/32163252

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Special Examinations—Breast, Genital, Prostate, and Rectal
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.
• 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.
• Review the Episodic note case study your instructor provides you for this week’s AssignmentBased on the Episodic note case study:
o consider the insights they provide about the case study.
o Search the online 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.