Nursing

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.

ANSWER

Genitalia Assessment

Subjective Portion

CC: External bumps on her genital areas.

HPI: AB is oriented and alter, comes to the clinic due to the external bumps on her genital areas. She states that the bumps feel rough and painless. She states that she is still sexually active and has had many partners during the previous year. She began her initial sexual contact at the age of 18. She does not complain of any abnormal virginal discharge. AB states that she is not sure how long the bumps have been there but she realized a week ago. Her last pap smear exam was three years ago, the exam results were normal and no dysplasia.  AB has finished the treatment for chlamydia as recommended.

Medications: Symbicort 160/4.5mcg

Allergies: NKDA

Past Medical History (PMH): Asthma

Family History (FH): There is no history of cervical cancer or breast. The father has a history of hypertension while the mother has a history of hypertension and Gastroesophageal reflux disease.

Social History: The patient denies using tobacco but occasional use of alcohol. She is married with three children two boys and one girl.

Additional Information on Subjective Portion

The past medical history should also include any surgeries and immunization status. The review of systems should be included in the subjective portion to understand the medical history of the patient. The review of systems offers essential information on symptoms such as fevers, vomiting, or diarrhea. The ROS will cover all body systems that will help the physician to rule out the differential diagnosis. Considerably, the patient states that the bumps are external on the genital areas but it is important for the patient to state any other symptoms or internal discomfort. For instance, the patient may state whether they had lesions anywhere else on their body. This may include characteristics of the lesions such as shape, pattern, size, and color. Therefore, the patient should be asked if they had any bumps on her genitalia in the past. The patient should be asked whether she has noticed any changes for the past week. Also, she should be asked whether he tried any medications and if there were any improvements noticed. The patient should also be asked whether they have any history of STI’s. Additionally, the subjection portion should also include her reproductive and sexual history such as contraception methods and menstrual history or any other risky sexual behaviors.

Objective

Vital signs: BP 120/86; WT 169lbs; Temp 98.6; P 92; HT 5’10”; RR 16.

Heart: The patient records regular rate and rhythm with no murmurs.

Lungs: symmetrical chest wall, CTA.

Genital: No swelling and massing. Usual female hair pattern distribution. Perineum intact, Urethral meatus intact without discharge or erythema. Vaginal mucosa moist and pink with rugae present, painless ulcer noticed in external labia.

Abdomen: normative and soft bowel sound, negative murphy’s, negative rebound, and negative McBurney.

Diagnostics: Herpes simplex virus specimen obtained.

Assessment: Chancre

Additional information on Objective Portion

The objective information included in the patient’s SOAP includes a general assessment of the patient, vital signs, and the physical examination results from laboratory diagnosis. The physical examination within the section should include the HEENT assessment and other assessments such as the cardiovascular, neck, musculoskeletal, skin, and neuro.

Assessment Support

The subjective and objective information offered has supported assessment and led to a logical assessment. Even though more details needed to be obtained from the patient, subjective and objective information have offered essential records such as signs and symptoms, medical history, the current condition through concerns, feelings, perceptions, and measurable data (Jensen, 2018). This information has been for the physician to gather essential information for reasonable differential diagnosis.

Diagnostics

Diagnostics are essential for identifying the microorganism causing the disease. Considerably, susceptibility testing is essential to make a diagnosis and prescribe the most effective treatment. The clinicians are aware that the results of testing affect the probability of the disease presence. For instance, the most appropriate diagnostic test is a pap test which should be obtained for the patient. This is because the patient has been having multiple sexual partners in the previous years. Pap test will indicate any abnormality in cells around the cervix (Philp et al., 2018). Other diagnostic tests such as darkfield microscopy should be ordered for Chancre. This is the most effective diagnosis for syphilis due to active chancre.

Differential Diagnosis

The current diagnosis is appropriate due to the personal history and symptoms offered by the patient. Due to the historical sexual contact and no recent pap test, the patient might have come into contact with the infection. The chancre is a result of bacterial infection that is spread through sexual contact which begins with a painless ulcer. Therefore, the current diagnosis is essential since the patient’s symptoms are similar to the disease symptoms.

The three possible differential diagnosis include:

1. Chancre-  The most common symptom for chancre is a bacterial infection that begins with a round, firm, and painless sore. The ulcer is the initial sign of syphilis which goes unnoticed and painless and that occurs within 2 weeks after infection (O’Byrne and MacPherson, 2019).
2. Granuloma Inguinale- This is a sexually transmitted disease that is caused by some bacteria which cause lesions in the genital and anal regions (Santiago-Wickey and Crosby, 2020). This leads to scarring and chronic inflammation of the genitals. The bacteria cause a painless and unnoticed red lump near the genitals which breaks down to a sore over time.
3. Molluscum Contagiosum- This is a viral skin infection that causes a mild skin disease that results in a firm, round and painless bumps (Leung, Barankin and Hon, 2017). The viral skin infection forms small bumps anywhere in the body but is painless. They are spread through body contact and disappear on their own on the skin.

References

Jensen, S. (2018). Nursing health assessment: A best practice approach. Lippincott Williams & Wilkins.

Leung, A. K., Barankin, B., & Hon, K. L. (2017). Molluscum contagiosum: an update. Recent patents on inflammation & allergy drug discovery, 11(1), 22-31.

O’Byrne, P., & MacPherson, P. (2019). Clinical updates: Syphilis. The BMJ, 365.

Philp, L., Jembere, N., Wang, L., Gao, J., Maguire, B., & Kupets, R. (2018). Pap tests in the diagnosis of cervical cancer: Help or hinder?. Gynecologic oncology, 150(1), 61-66.

Santiago-Wickey, J. N., & Crosby, B. (2020). Granuloma inguinale (donovanosis). StatPearls [Internet].