GENITALIA ASSESSMENT
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.
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
Assessment:
● Chancre
Case Study For Week 11
CASE STUDY 1 (A-G)
The parents of a 5-year-old boy have accompanied their son for his required physical examination before starting kindergarten. His parents are opposed to him receiving any vaccines.
REFERENCES
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
● Chapter 17, “Breasts and Axillae”
This chapter focuses on examining the breasts and axillae. The authors describe the examination procedures and the anatomy and physiology of breasts.
● Chapter 19, “Female Genitalia”
In this chapter, the authors explain how to conduct an examination of female genitalia. The chapter also describes the form and function of female genitalia.
● Chapter 20, “Male Genitalia”
The authors explain the biology of the penis, testicles, epididymides, scrotum, prostate gland, and seminal vesicles. Additionally, the chapter explains how to perform an exam of these areas.
● Chapter 21, “Anus, Rectum, and Prostate”
This chapter focuses on performing an exam of the anus, rectum, and prostate. The authors also explain the anatomy and physiology of the anus, rectum, and prostate.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 5, “Amenorrhea”
Amenorrhea, or the absence of menstruation, is the focus of this chapter. The authors include key questions to ask patients when taking histories and explain what to look for in the physical exam.
Chapter 6, “Breast Lumps and Nipple Discharge”
This chapter focuses on the important topic of breast lumps and nipple discharge. Because breast cancer is the most common type of cancer in women, it is important to get an accurate diagnosis. Information in the chapter includes key questions to ask and what to look for in the physical exam.
