Lab Assignment: Assessing the Genitalia and Rectum
Lab Assignment: Genitalia and Rectal Assessment of a Young Female Adult with a Raised Painless Vulval Genital Lesion
Sexually transmitted infections (STIs) are a common diagnosis in the United States between both males and females. One of the most important presentations of these STIs is a genital lesion which may be ulcerated or not. The genital lesion may also be either painful or not. Differentiation of the characteristics of the presenting genital lesion is at the root of making a correct diagnosis. It is however important to remember that there are many STIs that present as genital lesions. Lab Assignment: Assessing the Genitalia and Rectum. Even amongst those that present as painless lesions, there are several possibilities to choose from. Because of this alone, STIs presenting as genital lesions are a diagnostic minefield that must be treaded carefully with a keen eye on all the possible differential diagnoses. Patient AB in the episodic SOAP note in question is a young 21 year-old mother of three children who presents with a chief complaint of a genital lesion that is painless but “bumpy”. It is not accompanied by any discharge but feels rough. She admits to a history of previous chlamydia that she was treated for two years ago. She fits the high risk population demographic that is experiencing a scourge of STIs (Shannon, & Klausner, 2018). She particularly admits to having had sex with more than one partner in the past one year. This paper is about analyzing the accompanying episodic SOAP note documentation on this patent and filling in the missing information as well as agreeing with or disagreeing with the stated assessment. The paper will also list the most likely differential diagnoses in the order of likelihood.
Subjective Assessment of Patient AB
The documentation in the accompanying SOAP note for patient AB shows that it has correctly included the chief complaint, the history of presenting illness by way of the OLDCARTS mnemonic, current medications, allergies, past surgical history, past medical history, social history, and family history. Lab Assignment: Assessing the Genitalia and Rectum. It has however omitted the all important review of systems that is crucial in the subjective assessment of any patient (Ball et al., 2019). This is what is missing and needs to be included in that incomplete documentation as follows:
Review of Systems or ROS
General: The patient reports no fever, fatigue, or weakness.
HEENT: She has no double vision, blurred vision or any other problem with vision. She also does not report any hearing loss or otorrhea. She denies having a sore throat and also denies rhinorrhea or sneezing.
Integumentary: She reports no skin rash, dermatitis, eczema, or itchiness.
Gastrointestinal: She denies diarrhea, vomiting, or nausea. Her bowel movements are regular. She reports having her latest bowel movement on the morning of the visit.
Cardiovascular: She does not report any palpitations or chest pain of any form. She also denies any form of discoloration such as palor in her extremities.
Respiratory: The patient reports no cough, difficulty in breathing, or swelling of the limbs in any form.
Genitourinary: She denies any pain on micturition (dysuria) or any abnormal coloration of the urine. She states that she is not pregnant, with her LMP being on 25/10/2020. However, patient AB reports a painless “bump” on her external genitalia.
Neurological: She does not report any problems with bladder and bowel control. She also denies locomotor ataxia or paraesthesia.
Musculoskeletal: She denies any joint pains or muscle pain/ back pain.
Endocrinologic: She does not drink water excessively or pass urine in large volumes. She denies heat intolerance and excessive sweating under all circumstances.
Lymphatics: She reports no swollen and palpable nodes. She also states that she has never had any splenectomy operation in the past.
Hematologic: She denies bruising, dizziness, or fainting.
Psychiatric: She denies depression or any other form of mental illness.Lab Assignment: Assessing the Genitalia and Rectum.
Allergic/ Immunologic: She denies having any allergies related to the environment, food, or medications. She has also never suffered from allergic conditions such as asthma or rhinitis.
The objective Assessment of Patient AB
The documentation of the objective assessment for patient AB has been done quite well except for two particular shortcomings. One of the missing pieces of information is the general or constitutional assessment of the patient. This should have reported her general appearance and grooming, her level of consciousness or awareness, her mood and affect, her gait, as well as her insight. As expected, however, there is a documentation of her vital signs which show that she does not have a fever (T: 98.6°C or 37.0°C), has a blood pressure of 120/86 mmHg, has a pulse rate of 92, has a respiratory rate of 16, and a body mass index or BMI of 24.2 kg/m2 (because her weight is 169 pounds with a height of 5’10”). Appropriately, some selected body systems that are pertinent to the chief complaint (CC) and the HPI have been examined. Of note and importance is the genitourinary system the physical examination of which showed the presence on the external labia of small and painless ulcers that are characteristically round and firm. But the second shortcoming of this documentation is the fact that only one diagnostic test in the form of a herpes simplex virus (HSV) test has been done. Therefore, the missing information that needs to be added to this documentation in the section of objective evaluation is the other diagnostics that are needed to arrive at the various differential diagnoses. These are addressed below as well as their appropriateness for this case and how they are used to arrive at the diagnosis.
Additional Diagnostics Missing from the Objective Section Documentation, their Appropriateness in this Case, and How they are Used to Make a Diagnosis
Support of the Assessment by the Subjective and Objective Information, and Acceptance/ Rejection of the Current Diagnosis
The subjective and objective information is not fully supporting the current diagnosis of a chancre. As much as a chancre is not painful, it is usually not raised. The current diagnosis is therefore rejected in favor of a diagnosis of molluscum contagiosum (MC). The MC lesion is more in line with the findings in the subjective and objective assessments. This lesion is usually painless, raised, and bumpy (Meza-Romero et al., 2019).
Three Possible Differential Diagnoses
Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9th ed. Elsevier.
Ghanem, K.G., Ram, S., & Rice, P.A. (2020). The modern epidemic of syphilis. New England Journal of Medicine, 382(9), 845-854. https://doi.org/10.1056/NEJMra1901593
Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. McGraw-Hill Education.
Macpherson, P.A., & Cameron, D.W. (2017). Lymphogranuloma venereum, chancroid and granuloma inguinale. Infectious Diseases, 585–591.e1. http://dx.doi.org/10.1016/b978-0-7020-6285-8.00064-2
Meza-Romero, R., Navarrete-Dechent, C., & Downey, C. (2019). Molluscum contagiosum: An update and review of new perspectives in etiology, diagnosis, and treatment. Clinical, Cosmetic, and Investigational Dermatology, 12(1), 373-381. http://dx.doi.org/10.2147/CCID.S187224
Shannon, C.L. & Klausner, J.D. (2018). The growing epidemic of sexually transmitted infections in adolescents: A neglected population. Current Opinion in Pediatrics, 30(1), 137-143. http://dx.doi.org/10.1097/MOP.0000000000000578
Based on the Episodic note case study:
Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature. Lab Assignment: Assessing the Genitalia and Rectum.