Genitalia Assessment Assignment
Student’s Name
Institutional Affiliation
Genitalia Assessment Assignment
Additional Information on the Subjective Portion
According to the client’s personal information presented to the physician, she noticed the bumps in her genitalia region about one week ago, which means she is unsure when they first appeared. It is essential to ask the patient if she noticed the bumps if she had scabies or anyone else in their house, as this can also cause bumps on the genitalia. It is also vital to ask if she was infected with chlamydia two years ago if she experienced similar symptoms (Seidel et al., 2015). It is also essential to ask if the patient’s bumps always or do they come and disappear after some time.
It would also be essential for a physician to add information about the bumps’ aggravating factors by asking the patient if the bums are aggravated by warm or cold water, clothing, or heat. It would also be essential to ask if the patient has recently changed the soap or body detergent she uses (Seidel et al., 2015). It will also be necessary to ask about any other body parts that she might have noticed the bumps either internally or externally. There should also be some information on any alternative method that she has used to treat the bumps.
Additional Information on the Objective Portion
In the physical examination, it is essential to add the patient’s BMI, general stature, grooming, eye contact, and walking gait. It will also be necessary to assess the edema, see if there are any cold sores, oral thrush or tonsils, or any signs of a viral infection or systemic reaction, and add this information on this portion(Seidel et al., 2015). Information about her breathing, presence of any breast lumps, neck assessment for any nodal tenderness, and distension.
Because the patient has not had a Pap smear test for three years, it is vital to conduct one and add the results to the information in this portion. Also, performing a cervix inspection checking for tenderness and presentation, add the results information to the objective part (Seidel et al., 2015). Information about any virginal discharge, bleeding, and foul smell should also be added. Conduct a skin examination and add the warmth, dryness, discoloration, and pinkness of the skin to this section.
Does The Subjective And Objective Information support the assessment?
Yes, the assessment is supported by both objective and subjective information. Through personal information, a medical practitioner can predict what they can test for and give them a trajectory towards formulating a treatment plan. In this case, the patient’s information gave the doctor an idea of the problem at hand, which leads to the objective part of the data. Yes, diagnostics would be appropriate to determine the real problem that the patient is suffering from. The diagnostics can be done through the collection of an HSV specimen for viral culture. According to Gayet-Ageron et al. (2015), non-treponemal, EIA, VDRL, AND PVR tests for syphilis should also be carried out.
I would reject the diagnosis as the test is definite for HSV while the patient might be suffering from other infections. Ruling out this case as a herpes infection because of one ulcer on the labia is not conclusive. Since the patient has multiple sex partners and had an STD would make herpes progenitalis (Simplex II) is one of the possible conditions that the patient might be suffering from (Wagenlehner et al., 2016). The second possible condition that she might be suffering from is syphilis because she has had multiple sexual partners. Her ulcer is painless with no burning or itching syphilis is a possible diagnosis (Gayet-Ageron et al., 2015). The third possible infection that she might have is acute contact dermatitis as this condition is contact related and can be easily contacted. The client’s history could lead to this diagnosis.
Reference
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.
Gayet-Ageron, A., Sednaoui, P., Lautenschlager, S., Ferry, T., Toutous-Trellu, L., Cavassini, M., & Schrenzel, J. (2015). Use of Treponema pallidum PCR in the testing of ulcers for diagnosis of primary syphilis. Emerging infectious diseases, 21(1), 127
Seidel, H.M., Ball, J. S., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidels’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby
Wagenlehner, F. M., Brockmeyer, N. H., Discher, T., Friese, K., & Wichelhaus, T. A. (2016). The presentation, diagnosis, and treatment of sexually transmitted infections. Deutsches Ärzteblatt International, 113(1-2), 11 Genitalia Assessment SOAP note case study – Special Examinations—Breast, Genital, Prostate, and Rectal.