Special Examinations—Breast, Genital, Prostate, and Rectal

Special Examinations—Breast, Genital, Prostate, and Rectal

Special Examinations—Breast, Genital, Prostate, and Rectal

Thorough focused history and physical examination are required to make diagnoses and care plans for patients. The case provided is of a 21-year-old white female who complains of painless bumps in the genital area. On examination, a firm round painless ulcer is reported in the genital labia. Therefore, this paper will explain the missing aspects of the history and physical examination while giving the possible differential diagnoses.

Special Examinations—Breast, Genital, Prostate, and Rectal

Subjective Data

The significant systems of concern in this case study are mainly the genitourinary, integumentary, and reproductive systems. The history should provide complete significant negatives and positives of the patient (Sullivan, 2019). The general constitutional complaints such as weight loss, night sweats, and fever are missing from the SOAP note. These aspects are always important when classifying the patient’s illness into infectious, neoplastic, or other classes.

In the genitourinary system, the bump ought to be described further. The characteristics of dermatological conditions of the genitalia and perineum, such as itchiness, were missing from the provided history. For proper diagnosis, we need to rule out urinary pathology in the patient. The reproductive infection symptoms may usually occur together with urinary symptoms. Therefore, to be sure that there are no underlying urinary pathologies, the urinary symptoms of dysuria, dark urine, hesitancy, and incontinence would be included.

The patient is a female, and therefore, the gynecologic history must be included. There are a few elements of gynecologic reports. However, a comprehensive description of her menstruation is missing in the above history. Sometimes inflammatory conditions in the reproductive system can cause interruption of the menstrual patterns presentations. The presence of intermenstrual bleeding, irregular menses, and other menstruation abnormalities are missing from the provided history. Fortunately, the information about the Pap smear and STIs are reported. Sexual history is presented.

However, the 5 P’s of sexual history is incomplete. The aspect of Practices, Protection, and Pregnancy protection are not included. The provided history does not document the information about the specific sexual practices, methods of birth control, and protection against STIs. In the given sexual history, the findings on postcoital symptoms are missing. If present, such findings can be used to infer the presence or absence of cervicitis of possible cervical cancer because her last pap spear was three years ago. The component of HPV vaccination is not clear from the history provided.

Objective Data

A physical examination would majorly focus on the genital examination. The genital exam consists of the examination of the external genitalia, speculum examination of the external genitalia, bimanual examination, and rectovaginal examination (Ball et al., 2019, Special Examinations—Breast, Genital, Prostate, and Rectal). Specific to this case, the external genitalia examination and a rectovaginal exam are critical.

The external genitalia examination reported is missing the results of any lesions in the anus. Some lesions that affect the labia can affect the anus, such as warts and herpetic lesions. The rectovaginal exam findings are missing in the patient. In this patient, it would be appropriate to do a rectovaginal exam to rule out anal pathologies that share the same etiologies with labial infectious diseases. Internal genitalia examination and bimanual examination would not be mandatory, considering the history given lacks the symptoms of internal reproductive organ pathologies.

Another component of the physical exam that was missing was the examination of the lymphadenopathy. Inguinal lymph nodes drain the labia and perineal skin. Inguinal lymphadenopathy would signify that some infectious conditions are present, or the condition is metastatic cancer from the draining regions. It was, therefore, essential to report on the inguinal lymphadenopathy.

Diagnostics

In this case, appropriate diagnostic tests would include the Venereal Disease Research Lab (Chandrasekar & Bronze, 2017), antibody test for HSV, fluorescent treponemal antibody-absorption (FTA-ABS), and darkfield examination of ulcer swab. The results of these tests would confirm or rule out the presence of treponema species and HSV. The absence of treponemes and HSV would be used to make a diagnosis of chancroid (Buensalido et al., 2019). The diagnosis of chancroid will be supported by a thorough physical examination of the ulcer and the patient’s travel history.

Assessment

I would not entirely disagree with the assessment provided, although it is nonspecific. Chancre can arise from syphilis or chancroid. Both are infectious conditions that are caused by different agents. The description of the lesions can be clinically used to distinguish between the two conditions. In most cases, the syphilitic chancre is painless, while the chancre in chancroid is painful (Buensalido et al., 2019). Therefore, my priority differential diagnosis would be a syphilitic chancre.

Syphilitic chancre develops with primary syphilis. They are painless, round, punched out with rolled edges. On infrequent occasions, these lesions can be painful (Demir et al., 2016). The chancre develops within the first three to six weeks of incubation. In this patient, it is not clear when the symptoms first appeared. Other differential diagnoses that I would consider are chancroid, herpes simplex, psoriasis, and Behcet’s syndrome.

Herpes simplex infection presents with open ulcers on the labia and the anal region. The ulcers, blisters, or sores are usually multiple (Grove & Ramus, 2020). I would consider the possibility of genital herpes in this patient because of the lesions’ labial location, reproductive age, and since herpes is the commonest cause of genital ulcers in the US. However, herpetic genital ulcers are painful.

Chancroid would be a consideration in this case study; however, it is not common, and the presentations in this patient are typical except for the painless ulcers. Psoriasis and Behcet’s syndrome are likely differential diagnosis. Alongside mouth ulcers, Behcet’s syndrome presents with genital ulcers too. However, the presented data is insufficient to consider these differential diagnoses rather than the earlier mentioned diagnoses.

References for Special Examinations—Breast, Genital, Prostate, and Rectal

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Buensalido, J., Chandrasekar, P., & Sandejas, J. (2019). Chancroid Differential Diagnoses. Emedicine.medscape.com. Retrieved 3 November 2020, from https://emedicine.medscape.com/article/214737-differential?src=mbl_msp_android&ref=share.

Chandrasekar, P., & Bronze, M. (2017). Syphilis Workup: Approach Considerations, Imaging Studies, Lumbar Puncture. Emedicine.medscape.com. Retrieved 3 November 2020, from https://emedicine.medscape.com/article/229461-workup.

Demir, F., Salaeva, K., Altunay, I., & Yalcın, O. (2016). An extraordinary case of syphilis presenting with a labial ulcer. Saudi Medical Journal, 37(11), 1261-1264. https://doi.org/10.15537/smj.2016.11.15674

Grove, M., & Ramus, R. (2020). Genital Herpes in Pregnancy: Practice Essentials, Genital HSV Infections, Perinatal Transmission of HSV. Emedicine.medscape.com. Retrieved 3 November 2020, from https://emedicine.medscape.com/article/274874-overview?src=mbl_msp_android&ref=share#a2.

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