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
The Lab Assignment
Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature. Assessing the Genitalia and Rectum Essay
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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.
Assessing the Genitalia and Rectum: The Case of a 21 Year-Old Caucasian Female Mother of Three
Sexually transmitted infections (STIs) have characteristic presentations in both males and females. Usually, they present as lesions that could either be painful or not. Some lesions present as a bump while others present as an ulcer. Nurses and clinicians are therefore expected to be skilled in identifying the lesions correctly in order to arrive at the correct diagnosis and institute the correct treatment. Half of the 20 million patients treated each year for STIs in the US have been found to be adolescents and young adults (Shannon & Klausner, 2018). This paper is about a 21 year-old Caucasian mother of three children who presents to the clinic with painless external “bumps” on her external genitalia.
Subjective Portion
The additional information that should be included in the documentation for this patient is:
- The chief complaint
- The history of presenting illness (HPI)
- History of allergy
- Past medical and surgical history
- Family history
- Current medications
- Social history, and
- A review of systems or ROS.
Objective Portion
The additional information that is missing and requires being included in the documentation in this portion is:
- Constitutional evaluation (appearance, gait, awareness, grooming, and so on)
- Only an HSV specimen has been taken. This will only confirm or rule out herpes genitalis (Hammer & McPhee, 2018; Sauerbrei, 2016).
Support for the Assessment
The assessment of a chancre is not conclusively supported by the subjective and objective information. This is because even though a syphilitic chancre is painless, it is not characteristically raised as a bump. The patient’s lesions are raised and painless.
Diagnostics
These would be very appropriate for this case and they would be used to make a diagnosis s follows:
- Nucleic acid amplification testing (NAAT) for lymphogranuloma venereum or LGV. Swabs are taken from the external labia, the urethra, and the rectum for microscopic analysis that confirms or rules out LGV (Macpherson & Cameron, 2017).
- Rapid plasma reagin test is the serology test that rules out or confirms the presence of Treponema pallidum for syphilis (Ghanem et al., 2020).
- Dermoscopy where scrapings from the lesion are put under a microscope to confirm or rule out granuloma inguinale (Donovanosis) and molluscum contagiosum (Meza-Romero et al., 2019; Macpherson & Cameron, 2017). Assessing the Genitalia and Rectum Essay
Rejecting or Accepting the Current Diagnosis
I would reject the current diagnosis of syphilis (chancre). The reason is that the lesions are raised in contrast to what a syphilitic chancre would look like clinically. The subjective and objective information supports more a diagnosis of molluscum contagiosum whose lesions are raised, painless, and bumpy (Meza-Romero et al., 2019).
Three Possible Differential Diagnoses for this Patient
The primary diagnosis therefore is likely molluscum contagiosum as above noted. Three differential diagnoses would therefore be:
- Donovanosis (granuloma inguinale). Its genital lesions bleed readily but are normally painless (Hammer & McPhee, 2018; Macpherson & Cameron, 2017)
- Syphilitic chancres are usually painless but not bumpy (Hammer & McPhee, 2018; Ghanem et al., 2020)
- Lymphogranuloma venereum (LGV). Shows ulcerated lesions although these ones are not ulcerated (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, 8th 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 Assessing the Genitalia and Rectum Essay