Assignment: Lab Assignment: Assessing the Genitalia and Rectum

Assignment: Lab Assignment: Assessing the Genitalia and Rectum

Lab Assignment: Assessing the Genitalia and Rectum

The SOAP note portrays a 21-year-old White female patient presenting with external bumps on her genital area. She describes the bumps as painless and rough but denies having abnormal vaginal discharge.  The 21-year old patient tells the assessor that about 24 months ago, she suffered from chlamydia, which was managed using medication. This paper analyzes the SOAP note’s subjective, objective, and assessment portion and discusses the differential diagnoses.

Subjective Portion

Additional information needed in the HPI includes condoms use and the medication the patient used in treating chlamydia. The PMH should include information on the age the patient was diagnosed with asthma and history of the last asthma attack and hospitalization due to asthma. Additional information

is required on the allergies the patient has that trigger asthma attacks. The social history needs to encompass information regarding cultural practices, hobbies, sleeping patterns, diet, exercise, health promotion exercises, employment as well as the educational level. Furthermore, the subjective portion should include immunization status, surgical history, and reproductive health history. Moreover, there is a need to include a review of systems (ROS), which entails both positive and negative symptoms in the genitourinary, gastrointestinal, cardiovascular, respiratory and general systems.

Objective Portion

The objective section of the SOAP Note for this patient should have encompassed information on the general physical examination. This includes information on dressing and grooming, general health status, mood, speech, posture, gait, eye contact, and speech.  Since it is a focused exam of the genitalia and rectum, information should be provided on speculum examination, bimanual examination, and rectal exam findings.

Assessment

The identified differential is chancre. According to Roett (2020), chancre characterizes a type of ulcer that is painless and has a spotless base and indurated margin. In the case at hand, chancre is supported by the objective and subjective outcomes of the medical history of the patient entailing rough bumps seen on the outer parts of genitalia, which are painless.  The chancre differential is supported by the outcomes of the assessment that revealed a hard, tiny, round, and painless ulcer on the outer parts of labia.

Diagnostics

Diagnostics are essential for this case scenario to help determine the causative agent of the genital ulcer. A genital ulcer is a common manifestation in various STIs, including

HSV infection, chancroid, syphilis, granuloma inguinale, and lymphogranuloma venereum (Maliyar et al., 2019). There are various suggested diagnostic tests for the case such as HSV type-specific serology and the polymerase chain reaction testing. Serologic testing is needed to rule out syphilis and culture for H. ducreyi to rule out chancroid (Maliyar et al., 2019).In addition, genital swabs or bubo aspirate can be tested for C. trachomatis by different tests such as direct immunofluorescence, nucleic acid amplification or culture, to disqualify lymphogranuloma venereum.

Differential Diagnoses

Chancre is an expression that portrays a definite ulcer of genital and not a medical diagnosis. As such, it is appropriate to decline the existing chancre diagnosis because it is not deemed as a medical diagnosis term. Essentially, the conditions that may be deemed as differential diagnoses comprise:

Herpes simplex virus (HSV) infection

There are numerous early symptoms of the HSV infection such as several painless vesicular lacerations on the labia, vagina, foreskin, or rectum. According to Roett (2020), these vesicles habitually split impulsively and develop into sore, shallow ulcers. Prodromal symptoms often occur before the ulceration, including a mild tingling sensation or sharp pain in the hips, buttocks, or legs (Roett, 2020). Genital HSV is a differential diagnosis based on findings of painless rough external genital bumps and the presence of a hard, round, small, painless ulcer on the outer labia.

Primary Syphilis

The primary syphilis is majorly manifested through a painless ulcer that has spotless base and indurated margin. Primary syphilis typically presents with solitary lesions, but multiple lesions can occur (O’Byrne& MacPherson, 2019). Infected persons may develop unilateral or bilateral painless, non-suppurative inguinal adenopathy after the appearance of the chancre (O’Byrne& MacPherson, 2019). The medical assessment outcomes that are associated with primary syphilis include patient’s history of irregular peripheral bumps and discovery of solid, tiny, and painless ulcer located on the labia’s exterior. In addition, the patient admitted to having many sexual partners in the past, which makes her susceptible to STIs like syphilis.

Chancroid

Chancroid is characterized by painful and non-indurated ulcer of genital and a friable base and a serpiginous margin. Lautenschlager et al., (2017) noted that genital ulcers builds up on the penis’s prepuce and frenulum in male gender while in female, it builds up the cervix or vulva. In addition, infected persons have tender, suppurative, unilateral inguinal lymphadenopathy (Lautenschlager et al., 2017). Chancroid is a differential diagnosis depending on the existence of ulcer of genital on the labia’s exterior. However, the patient’s ulcer is painless, making it a less likely primary diagnosis.

Conclusion

The subjective portion should include additional information on contraceptive use, history of asthma, surgical, reproductive history, social history, and ROS. On the other hand, the objective portion needs to comprise of the outcomes from the general assessment, rectal, bimanual, and speculum assessments. It is recommended to conduct diagnostics to confirm or refute lymphogranuloma venereum, HSV infection, granuloma inguinale, syphilis, and chancroid. The possible differential diagnoses include HSV infection, syphilis, and chancroid.

References

Lautenschlager, S., Kemp, M., Christensen, J. J., Mayans, M. V., & Moi, H. (2017). 2017 European guideline for the management of chancroid. International journal of STD & AIDS, 28(4), 324-329. https://doi.org/10.1177/0956462416687913

Maliyar, K., Mufti, A., Syed, M., Selk, A., Dutil, M., Bunce, P. E., & Alavi, A. (2019). Genital ulcer disease: a review of pathogenesis and clinical features. Journal of cutaneous medicine and surgery, 23(6), 624-634. https://doi.org/10.1177/1203475419858955

O’Byrne, P., & MacPherson, P. (2019). Syphilis. BMJ (Clinical research ed.), 365, l4159. https://doi.org/10.1136/bmj.l4159

Roett, M. A. (2020). Genital Ulcers: Differential Diagnosis and Management. American Family Physician, 101(6), 355-361.