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
- 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)
- 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
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.
Expert Answer and Explanation
The diagnosis of sexually transmitted diseases includes choosing the type of discharge, blood tests, urine tests, and the examination of other physical symptoms such as pain during sexual intercourse or burning sensations during urination. The similarity of the symptoms of different STIs makes it hard for healthcare givers to easily pinpoint the exact disease that the patient suffers from (Ball et al., 2017). A close assessment of the objective and subjective information of AB, a 21 y.o. pt. with the symptoms of STIs, helps to assess the truthfulness of the diagnosis provided as well as to provide her a preferential diagnosis.
The patient has painless bumps in her genitalia, and these feel rough time to time. She does not have any abnormal vaginal discharge, and is unsure about the time the vaginal bumps appeared. However, she says she realized she has them about two weeks ago. Besides being sexually active since the age of 18, she says that she has had at least two sexual partners over the past one year. She has NKDA allergy, a past medical history of asthma, and she is also taking some medications including Symbicort. She also got Chlamydia at 19, and a pap smear conducted three years ago confirmed the absence of dysplasia. He has no breast cancer or cervical cancer history, but both parents have hx of HTN and GERD. The last part of the subjective information is that she has three children, abuses alcohol occasionally, but does not smoke. The additional subjective information could be assessing whether or not she is pregnant.
The vitals of the patient are as follows: Temp 98.6; HT 5’10”; BP 120/86; P 92; WT 169lbs, and RR 16. Her hurt does not show visible signs of murmurs, and a CTA of the lungs shows that they are symmetrical. The genital assessment shows the absence of swellings or masses, intact urethral meatus, and normal hair distribution. Also, the vaginal mucosa is pink as expected, but there is rugae. Also, there is a painless ulcer on the external labia of the vagina. The abdominal assessment shows soft bowel sounds that are normative, neg murphies, and neg rebound. For the diagnostics, a HSV specimen is obtained. Much of the objective information was captured, but the assessor should have collected blood and urine samples to assess them.
Support of the Assessment
Following the assessment of the objective and subjective data, the patient is diagnosed to have chancer, which is right considering the individual symptoms in the genital mucosa characteristics. Painless sores also confirm the presence of the condition.
(Asai et al., 2020).
The Appropriateness of the Diagnostics
While the diagnostics could appear perfect for the scenario, I believe they were not as appropriate as they failed to include crucial assessments that would help in clarity of the diagnosis. Specifically, there should have been the obtaining of blood, fluid, and urine samples which could not only help to identify the illness, but would indicate the exact stage (Janssen et al., 2020).
Rejecting the Diagnosis
I would be quick to reject the diagnosis because the screening was not sufficient enough to make a decision. That is, there is need for further examinations of fluids such as saliva, vaginal discharge, urine, and blood to identify whether the patient had chancre or other sexually transmitted infections or several combined disorders (Abdool Karim et al., 2019).
In the differential diagnosis, I would consider HPV to be one of the candidates of further examination as it is evident the patient was not aware of the rough sores, which could be indicative of an overgrowth of sores (McCabe et al., 2017). Also, after asking the patient whether they felt painful sensations during urinating I would judge whether or not they have gonorrhea, where I would perform further assessments. Other possible conditions could be Genital Herpes or Chlamydia (which often returns years after the first diagnosis) (Bakshi et al., 2018)
The information presented about patient AB is not sufficient enough to make a rational judgment of the sexually transmitted infection they may be having. While it is evident that the present diagnostics with the current subjective and objective data could be indicative of chancre, it is not easy to rule out other conditions at this early examination stage. The healthcare giver should perform further fluid assessments using saliva, urine, blood, and vaginal discharge samples, which could also help in deciding the stage of illness faced by the patient.
Abdool Karim, S. S., Baxter, C., Passmore, J. A. S., McKinnon, L. R., & Williams, B. L. (2019). The Genital Tract and Rectal Microbiomes: Their Role in HIV Susceptibility and Prevention in Women. Journal of the International AIDS Society, 22(5), e25300. https://doi.org/10.1002/jia2.25300
Asai, S., Kaneko, A., Matsuda, T., Takanashi, N., Doi, M., Atsumi, H., & Miyachi, H. (2020). Sonographic Appearance of Syphilitic Induration Mimicking Squamous Cell Carcinoma in the Lower Lip: A Case Report. Journal of Medical Case Reports, 14(1), 1-7. https://doi.org/10.1186/s13256-020-02547-x
Bakshi, R. K., Gupta, K., Jordan, S. J., Chi, X., Lensing, S. Y., Press, C. G., & Geisler, W. M. (2018). An adaptive Chlamydia trachomatis-specific IFN-γ-producing CD4+ T cell response is associated with protection against Chlamydia reinfection in women. Frontiers in immunology, 9, 1981. https://doi.org/10.3389/fimmu.2018.01981
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2017). Seidel’s Guide to Physical Examination-E-Book: An Interprofessional Approach. Elsevier Health Sciences.
Janssen, K. J., Wolffs, P., Lucchesi, M., Dukers-Muijrers, N. H., & Hoebe, C. J. (2020). Assessment of Rectal Chlamydia Trachomatis Viable Load in Women by Viability-PCR. Sexually Transmitted Infections, 96(2), 85-88. http://dx.doi.org/10.1136/sextrans-2019-054002
McCabe, B. E., Schaefer Solle, N., Peragallo Montano, N., & Mitrani, V. B. (2017). Alcohol misuse, depressive symptoms, and HIV/STI risks of US Hispanic women. Ethnicity & health, 22(5), 528-540. https://doi.org/10.1080/13557858.2016.1244738
Ramoni, S., Genovese, G., Pastena, A., & Cusini, M. (2020). Primary Syphilis of the Neck Mimicking Pyodermatitis. Sexually Transmitted Diseases, 47(10), e45-e46. Doi: 10.1097/OLQ.0000000000001210
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