From the case scenario, several components should be determined to identify the proper diagnosis in this case. A comprehensive subjective health history is vital information that, when used together with objective assessment and diagnostic tests, helps in determining the most appropriate diagnosis as well as a differential diagnosis. By further assessing and defining a detailed history will offer the scenario with a more comprehensive insight into the patient’s condition.
Additional Information for the Subjective Section
For the HPI, there is additional; information that the client should provide for further assessment of the chief complaint. Additional information regarding the HPI would be about how long the external bumps on her genital area last after appearing, and the characteristics of the external bumps like distribution, shape, size, and color. It would also be crucial to know whether it is the first time the patient is experiencing the external bumps in her genital area. Additional information would be about any related factors if the external bumps are worsened, or she feels irritation from wiping, or when she uses some lotions or products. Also, it would be essential to determine whether the patient had previous complaints of external bumps and whether she ever had treatment from any other medication prescribed for the condition (Sullivan, 2019). Further, since the patient states she has one sexual partner for the last one year, it would be important to know whether her sexual partner has over the previous year complained of external bumps around his genitalia, or whether the partner could have a history of HVS or recent diagnosis of any genital infection like syphilis.
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Additional Information for the Objective Section
Additional objective information that needs to be included in the documentation is information from a physical exam, including inspection and palpation of lesion, lymph nodes examination, and general examination including a thorough examination of oral cavity and skin of palms, torso, and soles, LN(s), spleen, and liver (Ball, Dains, Flynn, Solomon, & Stewart, 2019). Besides, information is needed on palpation – tenderness, the base of the ulcer, bleeding on manipulation, induration, attachment to surrounding structure, and per-rectal examination.
The Assessment
The assessment that has been made is the chancre, and this is supported by both objective and subjective information. Generally, a chancre is a painless genital ulcer and is transmitted through sexual intercourse. The fact that the patient is sexually active; thus, she might have contracted it through sexual contact with her partner. Besides, as indicated by the objective data, chancres are round, small, painless ulcers around the external genital area.
Diagnostics
A diagnostics would be suitable for this case as it would help perform various tests to ascertain the actual condition that the patient suffers from. An accurate diagnostics would help in identifying the real disease from a range of potential conditions which present similar symptoms, and give the patient the best chance for positive health results since the medical decision would be tailored to an accurate diagnosis of the health condition of the patient ( Holmboe & Durning, 2014) . The results from the diagnostic process would help in making a diagnosis by considering various diagnostic possibilities or hypotheses to explain the patient’s symptoms and would also improve the list of a differential diagnosis since further information will be gained in the diagnostic procedure.
Current Diagnosis
I would accept the current diagnosis because the objective and subjective data support the symptoms present in a chancre. For differential diagnosis, the three possible conditions which could be considered as a differential diagnosis for the patient are syphilis, chancroid, and herpes. Syphilis develops in phases, and symptoms vary in every stage. For primary syphilis, the initial manifestation of syphilis is a small ulcer or chancre. These chancres may spread around the genital areas. The chancres typically develop about three weeks after exposure, and most people with syphilis do not notice the chancre since it is usually painless. Similarly, for chancroid, women might develop several bumps on the labia, on the thighs, or between the anus and labia. The patient might also be suffering from herpes (Ball, Dains, Flynn, Solomon, & Stewart, 2019). This is an infection caused by HVS, and it affects the external genitalia, mucosal surfaces, anal region, and skin in other body parts. One of the primary symptoms of herpes is ulcers or chancres on the external genitalia, which might be painless at the initial stages.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel's guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Holmboe, E. S., & Durning, S. J. (2014). Assessing clinical reasoning: moving from in vitro to in vivo. Diagnosis , 1 (1), 111-117.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
