Genitalia Assessment Health, Medicine, Nursing Case Study

Genitalia Assessment
Your Name
Subject and Section
Professor’s Name
Date of Submission
Date of assessment: August 9, 2020
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 five small, painless, and rough bumps along her labia majora and six on her vagina which she noticed a week ago. She is sexually active and does not use condoms or vaginal diaphragms. Before they had sex, they usually inject drugs and share the needle. She had multiple partners in the past year and some of them had multiple partners also. She began engaging in sex when she was 18 y/o. There is no vaginal discharge.
PMH: The patient has asthma since childhood but it occurs only when she runs fast or in extreme weather conditions. She was diagnosed with chlamydia 2 years ago and she completed the treatment for it. 3 years ago, she had undergone a Pap smear and the result was normal without dysplasia. She did not have any recent surgeries or hospitalizations.
Immunizations: HBsAg and Tetanus toxoid in December 2018.
Medications: Symbicort 160/4.5mcg twice daily for maintenance. Combination pill (oral contraceptives) every day for maintenance. She does not take herbal or any OTC drugs.
Allergies: NKDA
FH: No hx of breast or cervical cancer. Father has a hx of HTN. Mother has a hx of HTN, GERD
Social: Denies tobacco use; occasional etoh; (+) illicit drug use. She is married with 3 children (1 girl and 2 boys) and lives in an apartment in a village. She is a working student and goes to school every MWF from 10 AM to 3 PM. She works full-time every TTh from 8 AM to 3 PM as a barista in Starbucks and part-time during MWF from 4 PM to 8 PM. During weekends, she spends time with her family by going to the park. Her husband is also a working student which makes them financially-challenged.
OB-GYN: Menstrual hx: Menarche at 11 y/o. LMP: August 5, 2020, heavy flow, 5 pads per day, the duration is 4 days. She does not experience PMS and contact or intermenstrual bleeding. Gynecologic hx: G3P3-3-0-0-3 all are NSVD. She uses oral contraceptives (combination pill) and does not miss a dose. She does not feel pain during sex. Does SBE every month and there are no lumps. No hx of gynecologic surgeries, infertility. She had vaginal discharges 2 years ago.
Psychosexual hx: The patient cannot hold on having sex regularly prompting her to cheat on her husband. Her libido is always high and likes to have an orgasm at least twice a week.
Review of Systems
GENERAL: No fever, chills, weight loss, weakness, or fatigue
HEENT: No visual loss, double or blurred vision. No hearing loss, sore throat, sneezing, problems of congestion. The patient sometimes experiences difficulty in breathing due to asthma. No lymphadenopathies on the cervical area.
SKIN: No itching or rashes on the extremities, trunk, and face.
CARDIOVASCULAR: No chest pain, pressure, or discomfort. Does not experience palpitations or high blood pressure.
RESPIRATORY: No SOB or cough.
GIT: No vomiting, nausea, bloody discharges, or abdominal pain. (+) hx of hepatitis B last July 2016.
NEUROLOGIC: No headache, syncope, dizziness, ataxia, tingling, or extremities. No changes in bladder and bowel control.
GENITOURINARY. No dyspareunia.
MUSCULOSKELETAL: No muscle, back, and joint pain or stiffness.
PSYCHIATRIC: (+) hx of depression and anxiety diagnosed last June 2019.
Objective:
General Survey: The patient is awake, alert, coherent, makes eye contact, and is oriented x 3. No signs of cardiorespiratory distress, appropriately dressed to the weather, ambulatory.
VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs
HEENT: No facial or head deformities. Non-icteric sclerae, no discharges on the punctae, pinkish conjunctivae on both eyes. Can hear properly; no nasal discharges; oral mucosa is pinkish with 3 small warts inside the lower lip. No lymphadenopathies or lymphadenitis.
Heart: No bruit, thrills, or murmurs; normal sinus rhythm; S1 at apex and S2 at the base.
Lungs: There is full symmetrical chest expansion. No deformities, no scars, and no retractions observed. No detected masses upon palpation. Equal tactile fremitus; Vesicular sounds heard on all lung fields.
Genital: Inverted pyramid hair distribution; no masses or swelling;
Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. The perineum is intact. Vaginal mucosa pink and moist with rugae present, pos for 2 firm, round, small (~3cm), painless ulcers noted on external labia; 5 small (~1cm), painless, rough papules along her labia majora, 6 inside the vagina; 2 warts around the anus. No vaginal discharges. DRE: Smooth and no masses along the rectal surface.
Abd: soft, normoactive bowel sounds, no tenderness, tympanitic upon percussion, neg rebound, neg murphy’s, neg McBurney. Normal liver size, no tenderness. Normal splenic size, no dullness on percussion.
Diagnostics:
The diagnostic examination is appropriate to establish a diagnosis for this case. Most of the time, sexually transmitted infections have the same clinical presentation. Hence, the results will distinguish the etiologic agents concerning the patient’s chief complaint. Furthermore, the tests will help identify whether the etiologic agent is susceptible or immune to some medications. With the information from the results, the health provider can determine the appropriate actions to cure the patient (Cristillo et al., 2017).
1 NAAT from all the possible entries of the organism to check for gonorrhea and chlamydia. A swab test shall be done in these areas. The patient is a candidate since she is below 25 years old and has the signs and symptoms of an STI CITATION Ame19 \l 13321 (American Academy of Family Physicians, 2019).
2 RRR test and serum FTA test to check for syphilis. Since the patient is not pregnant currently, she also has an increased predisposition to incurring the infection CITATION Ame19 \l 13321 (American Academy of Family Physicians, 2019).
3 Human Immunodeficiency Virus. Serum HIV test is advised for sexually active individuals, especially for ages 15-65 CITATION Ame19 \l 13321 (American Academy of Family Physicians, 2019).
4 Herpes Simplex Virus. For HSV, the IgG antibody test should be done to make an accurate diagnosis. The lesions shall be swabbed using cotton and the specime...