Genitalia and Rectum Issue Case Study

Genitalia and Rectum Issue Case Study

In the subjective p0rti0n 0f the SOAP n0te, m0re investigati0n needs t0 be c0nducted int0 the patient’s hist0ry 0f present illness (HPI) and health hist0ry. In the HPI, I w0uld investigate m0re int0 what the patient’s sexual practices and hist0ry pri0r t0 the bump appearing (Sullivan, 2020). F0r example, I w0uld ask the patient if she uses pr0tecti0n 0r c0ntracepti0n while with her partners, h0w many partners she has had, and if they are male, female 0r b0th (Sullivan, 2020).

Genitalia and Rectum Issue Case Study

I w0uld als0 ask if she had any recent trauma t0 the site fr0m activities such as shaving (Sullivan, 2020). It is als0 imp0rtant t0 check if the patient had any m0difying fact0rs 0r perf0rmed any treatments t0 the area such as l0ti0ns, creams, s0aps that c0uld cause irritati0n t0 the area (Sullivan, 2012). Obtaining the patients surgical hist0ry is als0 needed t0 understand the patient’s entire 0bstetric hist0ry (Sullivan, 2020). Fr0m the physical exam, the patient has a healed episi0t0my scar which suggests she has had a pr0cedure in that area, likely fr0m child birth (Sullivan, 2020).

In the 0bjective p0rti0n 0f the SOAP n0te, m0re detail is needed in the physical exam 0f the external genitalia t0 be c0nsistent with the patient’s subjective sympt0ms. Since the patient has a p0sitive finding 0n the external labia, m0re examinati0n detail needs t0 be added (Ball,et al., 2015). F0r example, palpati0n 0f the labia f0r symmetry 0f c0l0r, inflammati0n, irritati0n 0r exc0riati0n and swelling (Ball, et al., 2015).

Unilateral labial swelling, 0r irritati0n can indicate a Barth0lin gland infecti0n (Ball, et al., 2015). Milking 0f the Skene gland is als0 needed t0 pr0perly evaluate f0r infecti0n 0n the physical exam (Ball, et al., 2015). Since the patient d0es have a p0sitive finding 0n the external labia, I w0uld als0 palpate internally in 0rder t0 evaluate f0r 0ther internal sympt0ms such as p0lyps 0r fistulas (Ball,et al., 2015).

In addition to inspecting and palpating the perineum, a full inspection of the rectum and anus is needed, since infections of the vagina are easily transferred to the anus and rectum and vice versa, stemming from their close anatomical proximity (Ball,et al., 2015).

A proper full body skin and throat examination is also needed to evaluate for other signs of venereal disease, paying close attention to sores on the hands, feet and mouth (Ball,et al., 2015). Lymph and neurological examinations should also be conducted on patients with suspicion for sexually transmitted disease (STD), due to the effect certain STDs have on those systems (Ball,et al., 2015).

More diagnostic testing could also help narrow down the possible differential diagnoses. In addition to the HSV specimen collected, testing for syphilis antibodies with a Rapid plasma regain (RPR), Treponema pallidum test (T. Pallidum), and Venereal disease research laboratory (VDRL) should also be conducted (Keefe, 2018).

If the tests are positive, more specific testing should be done to confirm what stage the disease is in (Keefe, 2018). HIV testing, gonorrhea and chlamydia testing should also be conducted due to the patient being sexually active with more than one partner and the patient’s history of STDs (Ball, et al., 2015).

Negative STD results would require more testing of the bump (Ball, et al., 2015). A biopsy of the bump would help rule out vulva cancer if STD results were negative as well as testing for Human papillomavirus (HPV) (Jefferies & Clifford, 2011).

Differential Diagnosis

I would agree with the current diagnosis of chancre or Syphillis Infection. Syphillis symptoms usually include a solitary, painless indurated ulcer (chancre) with nontender bilateral lymphadenopathy (Keefe, 2018). It is transmitted via unprotected sexual contact with an infected person and should be suspected in patients who engage in high-risk sexual behavior (Keefe, 2018).

Early detection and treatment of syphilis is imperative due to the severe damage to the neurological, musculoskeletal and hepatic systems that can happen in untreated infections (Keefe, 2018). In addition to syphilis, differential diagnoses include, Genital Herpes infection, Bartholin cyst, and vulva cancer.

Genital herpes is a strain of the herpes virus (HSV1 or HSV2) that is transmitted via skin to skin contact with an infected individual (Whitehead, 2017). Signs and symptoms include painful or pruritic erythematous sores to genital, cervix, or anus (Whitehead, 2017). During the initial outbreak, malaise, headache and swollen lymph nodes might accompany sores (Whitehead, 2017).

Genital herpes sores are usually grouped together and rarely ever just solely one sore in one place, this fact makes diagnosis unlikely (Whitehead, 2017). HSV and HVC testing would provide a positive diagnosis (Whitehead, 2017). Complications from genital herpes include, increased susceptibility to other STDs, infection of newborns (can cause blindness, brain damage and death of newborns if infected), and meningitis (Whitehead, 2017).

A Bartholin Cyst is a cyst that develops on the Bartholin glands on either side of the vagina, near the labia (Summers, 2018). The Bartholin glands produce lubricating fluid that helps keep the vagina moist and balance the PH (Summers, 2018). When the ducts of these glands are blocked, they can form cysts (Summers, 2018). These cysts are usually not painful, unless they become infected and form an abscess (Summers, 2018).

Bartholin cyst are common in women in their twenties and decrease with age (Summers, 2018). The cyst can cause the labia to be asymmetrical or one labium to hang lower than the other based on their size (Summers, 2008). These cysts are fluid filled and would not be consistent with the physical exam findings as described (Summers, 2018).

Vulva Cancer is rare, accounting for only four percent of female reproductive cancers and usually appears as a painless lump 0n the vulva, which may be acc0mpanied with pruritis fr0m vaginal irritation (Jefferies & Clifford, 2020). Vulva cancer can appear similar to genital herpes and syphilis outbreak (Jefferies & Clifford, 2020).

Changes in skin color or feel of vulva can also be signs of vulva cancer (Jefferies & Clifford, 2020). A vulva biopsy is needed for definitive diagnosis (Jefferies & Clifford, 2020). Women ages 50 and over are more at risk for vulva cancer, which is inconsistent with the patient being in her early twenties (Jefferies & Clifford, 2020).

References

Genitalia and Rectum Issue Case Study Instructions

 Assignment: Lab Assignment: Assessing the Genitalia and Rectum
GENITALIA ASSESSMENT
Subjective:
CC:Â dysuria and urinary frequency
HPI:Â RG is a 30 year old female with increase urinary frequency and dysuria that began 3 days ago. Pain is intermittent and described a burning only in urination, but c/o flank pain since last night. Reports intermittent chills and fever. Used Tylenol for pain with no relief. She rates her pain 6/10 on urination. Reports a similar episode 3 years ago.
PMH:Â UTI 3 years ago
PSHx:Â Hysterectomy at 25 years
Medication:Â Tylenol 1000 mg PO every 6 hours for pain
FHx:Â Mother breast cancer ( alive) Father hypertension (alive)
Social:Â Single, no tobacco , works as a bartender, positive for ETOH
Allergies:Â PCN and Sulfa
LMP:Â N/A
Review of Symptoms:
General:Â Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
Abdominal:Â Denies nausea and vomiting. No appetite
Objective:
VS: Temp 100.9; BP: 136/80; RR 18; HT 6’.0”; WT 135lbs
Abdominal:Â Bowel sounds present x 4. Palpation pain in both lower quadrants. CVA tenderness
Diagnostics:Â Urine specimen collected, STD testing
Assessment:
UTI
STD
PLAN:Â This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
The Lab Assignment
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.