Assessing the Genitalia and Rectum
Student’s Name
Institutional Affiliations
Assessing the Genitalia and Rectum
It is important to collect a comprehensive medical history of a patient in order to gather adequate information for making a diagnosis. The healthcare provider usually combines subjective information collected from the patient with physical exam results to establish the origin of a patient’s symptoms (Dains et al., 2016). Some patients usually shy away from sharing medical information with healthcare providers, especially those with reproductive symptoms. This might prevent the healthcare provider from collecting sufficient information to make a diagnosis.
Subjective Portion
The subjective portion of the note has only included a pertinent history but does not include a review of systems. Therefore, there is a need to include additional information regarding how the patient is feeling in various body organs and systems (Dains et al., 2016). For instance, the systems that should be reviewed, considering the patient’s chief complaints include; head, eyes, ears, nose, and throat (HEENT), the cardiovascular, respiratory, abdominal, genitourinary, integumentary/skin, musculoskeletal, and neurological systems (Dains et al., 2016).
Objective Portion
The objective portion of the note has captured findings of the physical exam. Additional information that should be added to this section should be the results of the objective assessment of the head, eyes, ears, nose, and throat (HEENT), the skin, musculoskeletal, integumentary/skin, and urinary system (Dains et al., 2016). The healthcare provider should perform urinalysis as a diagnostic test to establish whether there are any issues with the patient’s urinary tract.
Appropriateness of the Assessment
Chancre has been given as the patient’s assessment. This assessment is supported by the objective and subjective portions of the note. Chancre is a sexually-transmitted disease. Females who are suffering from the condition normally present with ulcerated and painless sores on the genitals (Centers for Disease Control & Prevention, 2019). From the subjective data, it is evident that the patient is sexually active. The patient has further reported that she has external bumps in her genitalia. She also reports a history of chlamydia which is also a sexually-transmitted disease. From the objective data, the healthcare provider has noticed a painless ulcer on the patient’s external labia. These subjective and objective findings support the named diagnosis (Dains et al., 2016).
Diagnostic Tests
The assessment should direct the healthcare provider to perform other diagnostic tests. From the given data, Herpes Simplex Virus (HSV) specimen has already been collected. The specimen should be subjected to a direct test in the laboratory to isolate HSV (Nath et al., 2021). It is also necessary to obtain a bacterial culture of a vaginal swab to establish whether the patient has bacterial infections.
Rejecting/Accepting the Diagnosis
A patient’s symptoms must closely resemble the features of a disease for a diagnosis to be confirmed. I would accept the given diagnosis in the current scenario. The reason is that the patient has reported symptoms that closely resemble those of chancre (Dains et al., 2016). Other features of the disease such as the presence of ulcers in the patient’s genitalia have been confirmed through objective assessment.
Differential Diagnoses
Chancre (Primary diagnosis): This is confirmed by the presence of rough painless sores in the patient’s genitalia (American Academy of Family Physicians, 2021).
Herpes simplex: Genital lesions or ulcers are normally observed in individuals with herpes simplex. However, the condition also causes painful blisters and oral ulcers which are absent in the patient (Nath et al., 2021).
Syphilis: Individuals with syphilis normally have wart-like lesions which resemble the painless ulcers that occur in chancre. However, syphilis also causes mouth ulcers, malaise, fever, and maculopapular rash which are absent in the patient (Draeger, 2021).
References
American Academy of Family Physicians. (2021). Diagnosis and management of genital ulcers. https://www.aafp.org/afp/2012/0201/p254.html
Centers for Disease Control and Prevention. (2019). Sexually transmitted diseases (STDs). http://www.cdc.gov/std/#.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Draeger, E. (2021). Diagnosis and management of syphilis: a guide for GPs. Prescriber, 32(8-9), 13-17. https://doi.org/10.1002/psb.1937.
Nath, P., Kabir, M. A., Doust, S. K., & Ray, A. (2021). Diagnosis of herpes simplex virus: Laboratory and point-of-care techniques. Infectious Disease Reports, 13(2), 518–539. https://doi.org/10.3390/idr13020049