Assignment: Assessing the Genitalia and Rectum
Assignment: Assessing the Genitalia and Rectum
CC: “I have bumps on my bottom which I would like to be checked out.”
HPI: AB, a college student 21 years old WF came to the hospital complaining of external bumps on her genital area. She claims that the pumps feel rough and they are painless. She confirms being sexually active with multiple partners especially in the past years. She first encountered a sexual experience when she was 18 years old. She is quite not sure when the bumps started appearing but, she, however, came to notice them about a week before visiting the hospital. The last time she had a pap smear was three years ago, and the doctors did not find any dysplasia, as her results turned out to be normal. She, however, confirms only one sexually transmitted infection, chlamydia. She completed her treatment for chlamydia just as prescribed.
Medications: 160/4.5 mcg Symbicort
Allergies: No known drug or food allergies.
FH: She denies having a history of cervical or breast cancer. Her father had a history of HTN as well as her mother, together with GERD.
Social Hx: She denies ever using tobacco, but confirms using alcohol occasionally. She is married with three kids, I girl, and two boys.
VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs
Heart: no murmurs, RRR
Lungs: CTA, symmetrical chest wall.
Genitalia: Hair distribution is normal around her genitalia with no swelling or masses. The urethral meatus is normal with no discharge or erythema. The perineum is normal, with a healed scare from her past episiotomy. Her vaginal mucosa is moist and pink with rugae present, pos for firm, small, round, and painless ulcer spotted on the external labia.
Abdominal: Normoactive bowel sounds, soft, neg murphy’s, neg rebound, neg McBurney.
Diagnostic: HSV specimen was obtained.
Information Missing on the Subjective Data:
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For a substantial diagnosis, it is important for the nurse to gather as much subjective information as possible for a better understanding of the patient’s condition. For an instant, the history of presenting illness must also include a characteristic of the
pumps that the patient is complaining about, in terms of color, size and pattern (In Passos, 2018). Whether they have been the same or changing ever since she noticed them. Moreover, whether she has done anything to try and get rid of them. Consequently, given that her condition is situated around the genitalia, and she was previously diagnosed of chlamydia, it is important to find out whether the patient has ever experienced symptoms of eczema and psoriasis in the past (In Passos, 2018). Her immunization status is also vital as part of the subjective data. The nurse must also get information from the patient regarding her past surgical history and her hospitalization status, and the reason for hospitalization if any. The past medical history should also include the drugs that the patient took to manage her chlamydia. The patient social history should include information such as whether she uses any contraceptives or sexual protection. The subjective portion should also include a review of system with information regarding weight gain weight loss, HEENT, skin assessment, breast assessment, genitourinary, cardiovascular, respiratory, musculoskeletal, hematological and neurological assessments.
Information Missing on the Objective Data
The objective portion is the most crucial part of a patient’s history as it reports the findings upon physical examination. It should start with the vital signs of the patient, which have been included. However, BMI is missing. General information such as the patient’s conduct, alertness, grooming, and cleanliness should also be included. The HEENT portion should include information regarding her throat, tonsils, edema, drainage and whether there are lesions (In Passos, 2018). The neck should also be assessed for nodal tenderness or goiter. The chest region should be examined for non-labored breathing, nipple tenderness, and presence of breast nodules. The heart and the lung are also essential and information regarding whether the patient is experiencing wheezing, nasal flaring or retraction and heart rate, hear sounds, arrhythmias, and chest crackles should also be provided (In Passos, 2018). The genitourinary assessment should also include information regarding vaginal bleeding, vaginal discharge, frequency of the discharge and amount, and any abnormalities noted. The nurse should also conduct a rectal examination to check for lesions or masses.
Missing Diagnostic Tests
The patient needs to have a full pelvic examination, which includes biopsy and pap smear for the nurse to be able to rule out other sexually transmitted infections. Enzyme immunoassay test should also be done to check for indications of syphilis and herpes. Her blood should also be screened for HIV. A urinalysis and HCG tests are also necessary given that the patient has an STD, and if pregnant, might affect the baby. An acetic acid test is also necessary to rule out genital warts (Kedar, Mukhi, Waghulkar, & Goyal, 2015). This test will also be able to rule out underlying reasons for HPV given that this woman has multiple sexual partners.
Both the subjective and objective data have supported the patient data assessment. For instance, from the subjective data, the nurse was able to know the patient’s presenting condition, the duration, past medical history, and other symptoms which are crucial to make a diagnosis. The objective data provides the results of physical information to confirm and more weight to the subjective data, hence being able to have an opinion of what the patient might be suffering from (In Passos, 2018). However, without the lab tests provided above, a final diagnosis cannot be made. For instance, chancroid is confirmed by the presence of painful open sores around the genital, whereas the patient complained of painless bumps, overruling it as a preferential diagnosis.
- Syphilis: This is a sexually transmitted infection that is characterized by the presence of painless cores (chancre) around the genitalia in acute stages, which the patient is positive for. The infection can lie dormant in the patient’s body for several years. Syphilis mainly occurs in three stages; in the first stage, the patient will complain of having painful sore around her genital area, mouth or the bottom area, within the first ten days to three months of infection. The sores may get bigger with time. If untreated, the infection will progress to the second stage where the sores will disappear, and the patient might get rashes on her body, mostly on the palms of the hand and the soles of her feet. This stage is also accompanied by fever, headache, weight loss, hair loss and skin growth around the vulva (Klein, McLaud, & Rogers, 2015). The infection will then proceed to a latent stage before the third stage kicks in. The third stage is chronic infection where the condition might cause damage to the brain, nervous system and the heart.
- Genital Herpes: This is a sexually transmitted disease that is normally caused by the herpes simplex virus. It is characterized by a cracked, raw and red area around the genitals which is usually painless. Other symptoms include itching and small blisters that break open with time causing pain, headache, backaches, painful urination and flue like symptoms (OʼByrne, MacPherson, Kitson, & Bourgault, 2019). It is usually asymptomatic among most patients at first. However, upon an early treatment, the patient will recover within a short time of medical therapy.
- Genital Warts: This condition is sexually transmitted and mainly caused by certain types of HPV. They always appear on the skin around the genital area. This condition is mainly characterized by whitish or skin colored bumps on the vagina, vulva, cervix or the anus (OʼByrne, MacPherson, Kitson, & Bourgault, 2019). The bumps can either be big or small, one or numerous and sometimes painful or painless. Sometimes the patient might experience itchiness and bleeding from the genital area.
- Molluscum Contagion: This is a common viral infection of the skin especially on the genitalia. Elevated, pearl-like nodules or papules characterize it. The papules are usually painless with no itchy feeling just like in the patient above. This condition does not leave scars (OʼByrne, MacPherson, Kitson, & Bourgault, 2019). Most of the time, this condition resolves on itself even without treatment.
- Contact dermatitis: It is an allergic reaction that causes itchiness and redness of the skin; as a result to contact with an allergen. It is presented with symptoms such as red rash around the genitalia, dry, cracked and scaly skin, bumps and blisters that sometimes oozes, and swelling or burning sensation (Mowad et al., 2016).
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