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ACCESSING THE GENITALIA AND RECTUM

  • 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  3 different references from current evidence based literature. and list 5 differential diagnosis

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 over 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 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:

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

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