GENITALIA ASSESSMENT on Patient Assignment
GENITALIA ASSESSMENT on Patient Assignment
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
Review the Episodic note case study provided you for this week’s Assignment.
Based on the Episodic note case study:
Review this week’s Learning Resources and consider the insights they provide about the case study. Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.
Search the Walden library or the Internet for evidence-based resources to support your answers to the questions provided.
Consider what history would be necessary to collect from the patient in the case study.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
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ASSESSMENT OF GENITALIA ON PATIENT ASSIGNMENT
ASSESSMENT OF GENITALIA ON PATIENT ASSIGNMENT
HPI: AB, a 21-year-old WF college student, arrives at your clinic with external bleeding.
lumps on her genital region She claims the pimples are not painful but do feel rough. She claims to be sexually active and to have had more than one partner in the last year. Her first sexual encounter occurred when she was 18 years old. She notes that there is no abnormal vaginal discharge. She doesn’t know how long the bumps have been there, but she first noticed them approximately a week ago. Her most recent Pap smear exam was three years ago, and no abnormality was seen; the results were normal. She claims to have had one sexually transmitted infection (chlamydia) about two years ago. She completed the chlamydia therapy as directed.
PMH: Asthma
