Subjective Data:
Consider what history would be necessary to collect from the patient in the case study.
O: Last week, she discovered bumps but unsure how long they been there
So is this the first time you are noticing the bumps or have they occurred to you before? And if this is the first time you are noticing them, when did you start noticing them and what made you worry about them? Have you been recently sick or hospitalized by any chance whatsoever? If you were not sick, then have you by any chance been around someone who is sick? When was the last time you had a surgical operation if at all you had, or have you been recently directed to take any medication?
L: Has external genital bumps
Does any other part of your body have these bumps or are they only evident in your genital area? If they are only in your genitals, then can you be able to tell if any of them are located internally?
Delegate your assignment to our experts and they will do the rest.
C: The bumps feel rough but painless
How do the bumps feel, as in are they itchy or is there any burning sensation now that the bumps are there or are you experiencing anything different from what you were used to? What is the nature of the bumps when you touch them, are they soft or crusting over? Throughout the week, how have they been behaving, as in are they the same way they were when you first noticed them or have they been changing? Finally, are they by any chance spreading or they are just in the same place they were?
D: though the onset remain unknown, the bumps were discovered a week ago
When it comes to your daily routine, are the bumps always there 100% or do they come and go depending on the time of the day, or is it impossible to tell?
A: Do you know of anything that triggers the bumps to increase or worsen? Do you feel itching around the bumps when you put on tight under wears or use warm water? Do you shower using perfumed soaps? Have you used a different body soap, other than the one you are used to?
R: Have you found anything that makes the bumps disappear or reduce in number? Or anything that changes their textures, shapes, etc.?
T: Have you used any tropical medications or home remedies? If so, did you notice any improvement?
S: The bumps are painless, is that correct? No pain, but can you please rate how much you are bothered by the bumps? 1 denote the lowest affect while 5 denote the greatest affect.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition.
Past Medical History (PMH): Asthma, Chlamydia
Have you reported any case of STIs like genital herpes apart from chlamydia in the past? What drugs were you given when you had chlamydia and who gave you the prescription? How old were you when you were diagnosed with Asthma? Have you been immunized against diseases such as polio?
Past Surgical History (PSH):
Any surgery that have been performed on you? Like Cesarean section, Breast Biopsy etc
Hospitalizations or Past Injuries
Have you ever suffered any abdominal injuries as a teenager?
Medications: Symbicort 160/4.5mcg
Have you been hospitalized due to asthma? Do you have rescue inhaler? Do you use any contraception? If yes, when did you stated using? Are you using any skin care medications such as acne?
OTC Meds/Herbs or Supplements:
Do you use any of the following: work-out supplements, diet pills, enhancement drugs, herbs , vitamins or sexual pleasure creams?
Denies Hx of?
HIV, thyroid dx, Diabetes, Syphilis, Psoriasis, HSV, HPV, Candida or Recent Strep.
Allergies: NKDA
Do you have tropical or food allergies? What symptoms do you show when exposed to allergens?
Health Maintenance:
Last Eye Examination …?
Last Dental Appointment …?
Last PE with PCP …?
Sexual/Reproductive History: She is sexually and single active since age 18. For the last one year, had more than one partner. Contracted chlamydia 2 years ago and underwent a successful treatment regimen. Last pap 3 years ago normal with no dysplasia.
Did you get any other complications or weird conditions since the treatment of Chlamydia was completed? Did you use any protective measures when having sexual contact with all the partners mentioned? In regards to pregnancies, how many times have you been pregnant? And have there been any abortions or miscarriages in the process?
Personal/Social History: the patient is a married College student with 3 kids. One is a boy and the others are girls. She is a non-smoker but Occasional ETOH.
Do you live alone or with your partner, or generally, how is your living standard? Are you a working class, and if you are what kind of a job does you do? What are your hobbies as well as major activities? Since you are in school what are you studying?
Objective Data:
Physical Exam: Vital signs: T: 98.6, B/P 120/86, RR 16, P92 Ht 5’10” , Wt. 169 lbs.
Temp location, Arm and cuff size for B/P, BMI = 24.2.
HEENT: Assess throat for redness, edema, drainage, enlarged tonsils, cold sores, any lesions, thrush. Looking for systemic infection from HSV or another virus?
Genital/Rectal: Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact with a healed episiotomy scar present. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia
Lungs: CTA, Chest wall symmetrical. Do you experience any wheezing, retractions or nasal flaring?
Skin : Assess for pink, warm and dry. Inspect for other areas with lesions or redness. Any scaling or patches, discoloration.
How would the results be used to make a diagnosis?
The next step that will be carried out is the creation of a problem list and that is after the subjective and objective data have been prioritized. After the end of the prioritization of data has been accomplished and a diagnosis provided, then the following step will be about laboratory tests, as well as imaging studies and specialty consultations. Now, the findings that will be obtained from the studies conducted will then be added to the problem list especially if they are unknown. However, they should not drive one away from the main or primary issue previously discovered. The various methods that exist for making a proper diagnosis include recognizing patterns, using algorithms sampling, and the universe. One should not assume the findings from the first assumptions or just from the lab tests since one should conduct a proper examination first.
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Syphilis,
Herpes Progenitalis (Simplex II),
Herpes Progenitalis with asymptomatic Chlamydia,
Insect bites
Acute Contact Dermatitis
Diagnosis:
Labs: HSV Specimen for Viral Culture
The laboratory tests will mainly take up to 1 to 7 days before they are fully concluded. Tzanck smear – from the base of the vesicle is definitive for Herpes Virus (Cucci, 2015). Findings are multinucleated giant cells likely found if the specimen is from an intact herpes lesion (Dains, Baumann & Scheibel, 2015). PCR Rapid Tests -NAATs (Nucleic acid amplification tests) for Gonorrhea and Chlamydia with pelvic exam Consider KOH Wet Mount and PH Litmus depending on PE.
Look for clue cells, increased PH and a thin gray discharge. (Whiff test produces fishy odor and has PPV of 76% for BV (Sullivan, 2019)). Consider a U/A and test for gonorrhea and chlamydia Serum HCG Syphilis Serology
Nontreponemal and VDRL RPR and EIA tests. Acetic Acid Test detect subclinical lesions from HPV Scraping Looking for spirochetes
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
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.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical examination objective data checklist. In Mosby's guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
Cucci, E. Santoro, A., DiGesu, C., DiCerce, R., & Sallustio, G. (2015). Sclerosing adenosis of the breast: Report of two cases and review of the literature. Polish Journal of Radiology, 80 , 122–127. doi:10.12659/PJR.892706. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4356184/
