Special Examinations—Breast, Genital, Prostate, and Rectal

Special Examinations—Breast, Genital, Prostate, and RectalGENITALIA ASSESSMENTSubjective:• 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 externalbumps 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 thepast year. Her initial sexual contact occurred at age 18. She reports no abnormalvaginal discharge. She is unsure how long the bumps have been there butnoticed them about a week ago. Her last Pap smear exam was 3 years ago, andno dysplasia was found; the exam results were normal. She reports one sexuallytransmitted infection (chlamydia) about 2 years ago. She completed thetreatment 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. Urethralmeatus intact without erythema or discharge. Perineum intact. Vaginal mucosapink and moist with rugae present, pos for firm, round, small, painless ulcer notedon external labia• Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, negMcBurney• Diagnostics: HSV specimen obtainedAssessment:• ChancreUsing evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.Analyze the subjective portion of the note. List additional information that should be included in the documentation.Analyze the objective portion of the note. List additional information that should be included in the documentation.Is the assessment supported by the subjective and objective information? Why or why not?Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

 
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