AB a 21-year-old WF college student reports to your clinic with external bumps on her

AB a 21-year-old WF college student reports to your clinic with external bumps on her

GENITALIA ASSESSMENT

Subjective:

• CC: “I have bumps on my bottom that I want to have checked out.”
• HPI: AB a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had  more than one partner during the past year. Her initial sexual contact occurred at age 18.

She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week  ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She  reports one sexually transmitted infection (chlamydia) about 2 years ago.  She completed the treatment for chlamydia as prescribed.

• PMH: Asthma
• Medications: Symbicort 160/4.5mcg
• Allergies: NKDA
• FH: No hx of breast or cervical cancer,  Father hx HTN, Mother hx HTN, GERD
• Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:

• VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs
• Heart: RRR, no murmurs
• Lungs: CTA, chest wall symmetrical
• Genital: Normal female hair pattern distribution; no masses  or swelling. Urethral meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia.
• Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, negMcBurney
• Diagnostics: HSV specimen obtained

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.

Expert Answer and Explanation

The diagnosis of sexually transmitted diseases includes choosing the type of discharge, blood tests, urine tests, and the examination of other physical symptoms such as pain during sexual intercourse or burning sensations during urination. The similarity of the symptoms of different STIs makes it hard for healthcare givers to easily pinpoint the exact disease that the patient suffers from (Ball et al., 2017). A close assessment of the objective and subjective information of AB, a 21 y.o. pt. with the symptoms of STIs, helps to assess the truthfulness of the diagnosis provided as well as to provide her a preferential diagnosis.

Subjective Data

The patient has painless bumps in her genitalia, and these feel rough time to time. She does not have any abnormal vaginal discharge, and is unsure about the time the vaginal bumps appeared. However, she says she realized she has them about two weeks ago. Besides being sexually active since the age of 18, she says that she has had at least two sexual partners over the past one year. She has NKDA allergy, a past