Lab Assignment: Assessing the Genitalia and Rectum

GENITALIA ASSESSMENT

Episodic SOAP Note

 

Patient Initials: A.B.                             Age: 21                                          Gender: Female

 

CC: “I have bumps on my bottom that I want to have checked out.”

HPI: A.B., 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. Lab Assignment: Assessing the Genitalia and Rectum

 

Subjective:

 

Onset: unsure

Location: genital area

Duration: she knows at least a week

Character: painless but rough

Alleviating/Aggravating Symptoms: Nothing aggravates or alleviates

Treatment: No medications tried

Severity: 0 out 10 on pain scale

 

Medications:

Symbicort 160/4.5mcg – 2 puffs twice a day

Singulair 10mg by mouth daily

Zyrtec OTC-one tablet by mouth as needed

 

Allergies: NKDA, seasonal allergies

 

PMH: Asthma, hx of chlamydia

 

Past Surgical History (PSH): Hernia repair in 2011

 

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). She reports more than one sexual partner over the past year. Last pap was 3 years ago, visits the dentist twice a year, and gets eye exam every 2 years. She states she

 

General:  Denies weight loss, fever, chills, weakness, or fatigue.

HEENT:  Eyes:  Denies visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.

Skin: intact with no lesions except on her genital area

Cardiovascular: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

Respiratory: Denies shortness of breath, cough or dyspnea.

Gastrointestinal:  Denies any abdominal pain, nausea, vomiting diarrhea, or constipation. Positive for lesion on genital area that is rough but painless.

GU: Denies dysuria, incontinence, hesitancy, frequency or other abnormalities when voiding. Last pap smear was 3 years ago and showed no dysplasia. She denies any abnormal vaginal discharge but does have rough, painless bumps on genital area.

Neurological:  Denies headaches, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities, seizures, of falls. No change in bowel or bladder control.

Musculoskeletal:  Denies any muscle, back pain, joint pain or stiffness. Full ROM in all extremities, no muscle or back pain. Denies fatigue

Hematologic: Denies any bleeding or bruising.

Lymphatics:  Denies enlarged nodes. No history of splenectomy.

Psych:  Denies depression or anxiety. Normal affect

Endocrine: Denies sweating, cold or heat intolerance. Denies polyuria or polydipsia. Denies any endocrine symptoms or hormone therapies.

Sexual/Reproductive History: Heterosexual female who is married with 3 children. 2 are boys ages 3 and 1. 1 daughter who is 2. She is not monogamous with her husband and has had more than one sexual partner in the past year. She does not use contraceptives. She begins menstruation at age 16. She states that she has a 4-day menstrual cycle with no changes in the past year. Lab Assignment: Assessing the Genitalia and Rectum

Allergies:  Reports seasonal allergies, NKDA, denies hives, eczema or rhinitis. Positive for asthma

 

Objective:

 

General: AAO x 4, denies weakness, denies fatigue, well groomed, well nourished.

 

VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs

 

HEENT: Head is normocephalic. PERRLA. Tympanic membranes are intact with no drainage. Denies any congestion or nasal discharge.

 

Neck: Has smooth, controlled, full range of motion of neck. Thyroid gland non-visible but palpable with swallowing. Trachea is midline. Lymph nodes nonpalpable.

 

Chest: There is symmetry in chest wall expansion and diaphragmatic

excursion. Respirations 16/minute, relaxed and even without use of ancillary muscles

 

Heart: RRR, no murmurs, carotid pulse equal bilaterally, 2+. No bruits auscultated over carotids. Apical pulse 92 beats/minute, regular rhythm, with S1 heard best at apex, S2 heard best at base

 

Lungs: CTA, chest wall symmetrical. Breath sounds clear to auscultation in all lung fields.

 

Peripheral Vascular: Arms are equal in size, no swelling, pinkish skin tone, no clubbing of finger tips. Capillary refill time less than 2 seconds. Radial and brachial pulses strong bilaterally, Legs are warm bilaterally and pink in color from toes with normal distribution of hair. No ulcers or edema present. Femoral, popliteal, dorsalis pedis, and posterior tibial pulses strongly palpated bilaterally

 

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

 

Musculoskeletal: (CN II-XII grossly intact) Has upright posture and steady gait. He can maintain a heel toe walking. Full ROM of TMJ with no pain, tenderness, clicking, or crepitus. Normal curves of cervical, thoracic, and lumbar spine. Full ROM of cervical and lumbar spine. Full smooth ROM against gravity and resistance.

 

Neurological: Identifies correct scents. Vision 20/20. Full visual fields intact. PERRLA. Patient able to identify light, sharp, and dull touch to forehead, cheek, and chin. Ability to smile, frown, wrinkle forehead, show teeth, purse lips, and raise eyebrows. Gag reflux present, equal shoulder shrug against resistance, and able to turn head in both directions against resistance. Lab Assignment: Assessing the Genitalia and Rectum

 

 

Diagnostics:

HSV specimen obtained

 

Pap smear

HPV testing

Gonorrhea/Chlamydia testing

HIV testing

Pregnancy test

Assessment:

· Chancre

Differential Diagnoses

1. Condyloma Acuminate

Condyloma acuminate are also known as genital warts and are caused by the human papillomavirus (HPV). It is considered a sexually transmitted disease and can be dormant for months to years after exposure. They may be the same color as the skin or reddish and are usually painless and occur on the labia, the vestibule, or the perianal area (Ball, Dains, Flynn, Solomon, & Stewart, 2019). Smaller lesions tend to cause less symptoms but as the lesions become larger, they can bleed and become painful. Genital warts can be a precursor to genital cancer and can occur in the vagina, cervix, anus, or perineum (Dains, Baumann, & Scheibel, 2016).

2. Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) occurs after a hair follicle becomes obstructed and an infection of the follicle arises. These follicles become aggravated and if not treated, can become extremely painful. This conditions most often occurs in the axillary, inguinal, and genital areas and some research has suggested an infectious component (Parikh, Ferenczi, Finch, 2017). This diagnosis is an option due to bumps but is eliminated due to no pain being identified even after a week. Also, there is no inflammation or redness noted.

3. Molluscum Contagiosum

Molluscum contagiosum are papules that are sexually transmitted. They are usually found on the labia, perineum, and anal areas and are approximately two to five millimeters and flesh-toned (Dains, Baumann, & Scheibel, 2016). Molluscum contagiosum are cause by a virus that occurs with genital lesions after a cultivation period. They are typically painless and are diagnosed based on its appearance (Ball, Dains, Flynn, Solomon, & Stewart, 2019). Interviewing the patient about the spread of the bumps over the past week will help to eliminate or confirm this diagnosis. Lab Assignment: Assessing the Genitalia and Rectum

4. Herpes (Simplex II)

Herpes simplex II is almost exclusively sexually transmitted, causing infection in the genital or anal area (Dains, Baumann, & Scheibel, 2016). The bump is described as firm and starts off as one lesion. The lesion are often painful and can burn with the patient often complaining of burning with urination. A.B. does not complain of any pain with urination or any pain from lesion therefore, this could likely be ruled out.

5. Herpes with Asymptomatic Chlamydia

Unlikely but due to A.B.’s prior history of chlamydia and her current sexual habits and the fact that chlamydia can be asymptomatic, I believe the possibility of her having chlamydia with herpes should be taken into consideration. The physical exam may aid in ruling this out. An order for a rapid test would help deliver a definitive diagnosis (Dains, Baumann, & Scheibel, 2016)

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

Analyses of and Additional Subjective Data

When interviewing a patient, it is important to ask pertinent questions. A.B. does not mention any pain nor does he state if the pain radiates. An advanced practice nurse must inquire about these things. Knowing if there is anything that aggravates her bumps or increases the appearance of the bumps is necessary as well. Another question to aid in this assessment is what made her notice the bumps a week ago? The patient further reports that she is sexually active and has had more than one partner in the past year which could lead to her having a sexually transmitted disease. She also reports of no abnormal virginal discharge which indicates that she is not suffering from an infection which mostly causes the abnormal discharge (Dains, Baumann, & Scheibel, 2016). Further medical history indicates that she last had a Pap smear exam over 3 years ago where the results were normal. However, it is possible that the patient could be having cancerous cells that have occurred within the last three years. Some genital sores could be noncancerous cysts that may not require any treatment and can be easily removed in case they are bothersome. Other types of bumps could be cancerous and that would enable the doctor to develop an effective treatment. AB did provide information to her complaint. She provided pertinent information for a genital concern which includes gynecological background, family history, sexual history, general and specific risk factors, and surgical history (LeBlond, Brown,& DeGowin, 2014). But we should also inquire whether the bumps have been changed in size, if it affected her sexual life, and if she has noticed any increase or decrease in bumps in the past week. Critical information that should have been included in this assessment is whether the patient has used contraceptives and what types as the bumps could be as a result of these contraceptives.

Analysis of Objective Data

What the provider observes, vital signs, a general assessment of the patient, physical examination findings, and results from laboratory or diagnostic studies are all objective information (Sullivan, 2019). The objective data collected was in normal limits. The only body system that revealed abnormalities was the genital examination. An observation of the client’s genital area shows that there are normal conditions in terms of distribution of hair patterns and no abnormal discharge. There is the presence of a healed episiotomy scar which cannot be attributed to have caused the bumps. However, the pink virginal mucosa can also indicate an infection in the urethra. Also, it is important to understand that the patient has small and painless ulcers on the external labia. This indicated that the bumps were unrelated to the ulcer which could have been caused by sexual activities rather than an infection. This objective data aids in confirming the diagnosis of a chancre. Lab Assignment: Assessing the Genitalia and Rectum

Diagnostic Tests

The additional diagnostic test helps to rule out different possible diagnosis. An HSV specimen is recovered by swabbing mucocutaneous genital lesions and from previously involved mucocutaneous sites in patients with asymptomatic infection (Singh, Preiksaitis, Ferenczy, & Romanowski, 2005). HSV Specimen for Viral Culture – most specific results can take 1 to 7 days (Dains, Baumann & Scheibel, 2018). Specimens obtained from vesicular lesions within the first three days after their appearance are the specimens of choice, but other lesion material from older lesions or swabs of genital secretions should be obtained if suspicion of HSV infection is high (Singh, Preiksaitis, Ferenczy, & Romanowski, 2005). A pap smear is a diagnostic tool to examine a patient for viral infections like human papilloma virus (HPV) infection and Herpes can also be detected (Dixit, Bhavsar, & Marfatia, 2011). Gonorrhea is often asymptomatic in females (Piszczek, St Jean, & Khaliq, 2015). Due A.B. having a previous STD and being with multiple partners. It is a good idea to screen her for gonorrhea, chlamydia, and HIV.

Accept or Reject Diagnosis

In regard to the diagnosis of chancre, I do feel as if it is supported by the information given. The assessment is supported by the subjective and objective information provided by the patient and provider. A chancre is an ulcer that occurs in primary syphilis at the location of initial exposure to the disease (Henao-Martínez & Johnson, 2014). Syphilis usually causes a single lesion, or chancre, unless the patient is immunocompromised (Dains, Baumann, & Scheibel, 2016). A chancre lesion may sometimes be found internally. The lesion is raised, usually 1-2 centimeters in diameter, and with an indurated border (Riaz & Wei, 2017). Chancre- consist of painless ulcerative lesion or sores, usually seen near the genital region. The disease is contagious, lasting 1-5 weeks, and spread from skin to skin contact with open lesions or sores (Wolujewicz & Bates, 2016).

A.B. is at high risk of contracting sexually transmitted diseases due to her sexual activity with multiple partners as well as being married. We should encourage her on to use condoms to prevent the development of STD’s and decrease the risk of certain cancers such as cervical which can make one more prone to genital warts (Dains, Baumann, & Scheibel, 2016). painless ulcer suggests syphilis which can appear as a solitary lesion or more than one chancre, especially if the patient is immunocompromised (Dains, Baumann, & Scheibel, 2016). Examination of the genital notes a firm, round, small, painless ulcer on external labia which supports the assessment. Lab Assignment: Assessing the Genitalia and Rectum

Conclusion

Genital and rectal complaints can be a very sensitive topic for patients. It is important that as an advanced practitioner, that we provide accurate subjective and objective examinations. In this case study we must treat our patient and coincidentally potentially two others based on her diagnosis.

References

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.

Dixit, R., Bhavsar, C., & Marfatia, Y. S. (2011). Laboratory diagnosis of human papillomavirus

 

virus infection in female genital tract. Indian journal of sexually transmitted diseases and

 

AIDS, 32(1), 50-2. doi: 10.4103/2589-0557.81257

 

Henao-Martínez, A. F., & Johnson, S. C. (2014). Diagnostic tests for syphilis: New tests and new

 

algorithms. Neurology. Clinical practice, 4(2), 114-122.

 

LeBlond, R. F., Brown, D. D., &DeGowin, R. L. (2014). DeGowin’s diagnostic examination

 

(10th ed.). New York, NY: McGraw Hill Medical

 

LeGoff, J., Péré, H., & Bélec, L. (2014). Diagnosis of genital herpes simplex virus infection in

 

the clinical laboratory. Virology journal, 11, 83. doi:10.1186/1743-422X-11-83

 

Piszczek, J., St Jean, R., & Khaliq, Y. (2015). Gonorrhea: Treatment update for an increasingly

 

resistant organism. Canadian pharmacists journal : CPJ = Revue des pharmaciens du

 

Canada : RPC, 148(2), 82-9.

 

Riaz, A. & Wei, G. (2017). Chancre of primary syphilis. Journal of Education and Teaching in

Emergency Medicine, 2(4), V33. doi: https://doi.org/10.21980/J83342

 

Singh, A., Preiksaitis, J., Ferenczy, A., & Romanowski, B. (2005). The laboratory diagnosis of

herpes simplex virus infections. The Canadian journal of infectious diseases & medical

microbiology = Journal canadien des maladies infectieuses et de la microbiologie

medicale, 16(2), 92-8. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095011/

Sullivan, D.D. (2019). Guide to clinical documentation (3rd ed.) Philadelphia, PA: F.A. Davis

Wolujewicz, A. & Bates, C. (2016). Syphilis on the face in primary care: a rare sign of an

increasingly common problem. The British Journal of General Practice: the journal of

the Royal College of General Practitioners. doi: 10.3399/bjgp16X686065