Assessing The Genitalia And Rectum

ASSESSING THE GENITALIA AND RECTUM

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Analysis of the subjective portion of the note

The subjective portion of the notes contains what the patient says about the issue and intervention (Wolujewicz & Bates, 2016). From the subjective notes, unmistakably, the chief complaint of the patient can be expressed as “I have bumps on my genital areas. The bumps are painless and feel rough.” The History of Present Illness (HPI) showed that the area of bumps is on her genital areas. About the onset, I saw the bumps one week ago even though they are painless and feel rough. Her Past Medical History (PMH) shows that she has had one sexually transmitted disease (chlamydia) two years prior. She was additionally diagnosed to have asthma.

The additional information that should be included in the documentation some of the information I would need would be based on;

a.The present of itching or burning on the bumps.

b.The size of the bumps and whether the bumps look the same or have changed the appearance.

c.I will also consider information on past histories such as Genital Herpes or other STIs other than Chlamydia, date of immunization, the age for Asthma diagnosis, and Past Surgical History (PSH) such as female surgeries or C-sections.

d.I will also consider information as to whether the patient is using a rescue inhaler or ever been hospitalized for asthma.

e.When it comes to sexual history, I will ask whether the patient experienced any health problem after Chlamydia treatment was completed. I will confirm the number of sexual partners and whether they use protection.

Analysis of the objective portion of the note and additional information that should be included in the documentation

The objective section includes observations, results of the standardized and non-standardized assessment (Wolujewicz & Bates, 2016). When it comes to vital signs which include WT 170lbs; HT 5’9; P 92; RR 16; BP 120/86; Temp 98.6; I will go-ahead to include information on Temp location, Arm and cuff size for B/P. I will describe the general appearance of the patient, such as being active and alert, cleanliness, and grooming. I will also include information on HEENT, such as assessing throat redness, enlarged tonsils, and systemic infection from HSV. Since the heart is reported as RRR and no murmurs, I will further evaluate information such as peripheral pulses and edema. The chest wall is symmetrical. The assessment of genital areas indicates normal hair distribution with no evidenced of inflammation or masses, no erythema or discharge, but there is the presence of healed episiotomy scar present.

Assessment

According to SOAP notes, assessment is supported by both the subjective and objective information. This is because it is under the subjective data that a nurse can know what the patient is feeling or experiencing with the current illness and, therefore, determine the symptoms associated with the diagnosed condition. For instance, the first stage of syphilis is the development of round, firm, and painless sores, just as reported by the patient under the subjective notes. Under the objective notes, we have vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia, which are second-stage symptoms of the chancre.

Physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition.

Physical exams – As part of the initial physical examination for this patient, clinicians should examine all skin and mucosal surfaces for lesions, especially less-visible areas, such as the oropharynx, urethra, vulva, vagina, cervix, and anus.

Diagnostic tests – HSV specimen tests can be taken as the first diagnostic test from the viral culture. To test herpes simplex, Polymerase Chain Reaction can be used to confirm the diagnosis (Ellis, 2019). To rule out syphilis, serology test in the form of RPR, VDRL, or non-treponemal pallidum test would be done. Lastly, rapid Nucleic Acid Amplification tests would be done to rule out Gonorrhea and Chlamydia (Dains, Baumann & Scheibel, 2015).

Diagnosis for the given case

The diagnostics which is based on HSV specimen obtained would not be appropriate for this case because the patient does not have symptoms associated with Herpes Simplex Virus such as scorching wounds on the genitals or in the mouth, experiencing pain and itching while urinating (Dains, Baumann & Scheibel, 2015). Nevertheless, the result would be used to rule out the presence of the Herpes Simplex Virus.

The current diagnosis is chancre, and I would accept this because the patient has typical symptoms of chancre such as the development of the round, firm, and painless sores (Nasser et al., 2014). The following three diseases might be termed as a differential diagnosis for our patient:

a.Contact dermatitis (Rycroft et al., 2013)

b.Bartholin’s cysts (Nasser et al., 2014)

c.Herpes Progenitalis

d.Syphilis (Wolujewicz & Bates, 2016)

References

Dains, J. E., Baumann, L. C., & Scheibel, P. (2015). Advanced Health Assessment & Clinical Diagnosis in Primary Care-E-Book. Elsevier Health Sciences.

Ellis, P. (2019). Evidence-based practice in nursing. Learning Matters.

Nasser, H. A., Mendes, V. M., Zein, F., Tanios, B. Y., & Berjaoui, T. (January 01, 2014). Complicated rectovaginal fistula secondary to Bartholin’s cyst infection. The Journal of Obstetrics and Gynaecology Research, 40, 4, 1141-4.

Rycroft, R. J., Menné, T., Frosch, P. J., & Lepoittevin, J. P. (Eds.). (2013). Textbook of contact dermatitis. Springer Science & Business Media.

Slade, J., Hall, J. V., Kintner, J., & Schoborg, R. V. (2016). Chlamydial pre-infection protects from subsequent herpes simplex virus-2 challenge in a murine vaginal super-infection model. PloS one, 11(1), e0146186.

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, 66(648), e528.