Assessing the Genitalia and Rectum

Assessing the Genitalia and Rectum
Patient Initials: AB Age: 21yo Gender: Female
Chief Complaint (CC): “I have bumps on my bottom that I want to have checked out.”
Collection of History
In the case scenario provided the patient states “I have bumps on my bottom that I want
to have checked out.” The onset is identified as approximately seven days ago but uncertain how
long the “bumps” have been present. The patient does report a history of chlamydia with proper
treatment. It would be wise to identify if the patient has had any other sexually transmitted
infections (STI’s) or has her sexual partners reported any occurrences of STI’s. Given the
patient’s history of STI’s it would be appropriate lean toward a diagnosis of an STI.
Diagnostic Tests
STIs can be hard to diagnose because all of these may cause various symptoms, but are
asymptomatic. In this case, the suggested diagnosis tests will include blood tests for human HIV,
syphilis later phases, urine and gonorrhea tests, and a pap smear test that would determine
cervical anomalies and human papillomavirus (HPV). Tests for human chlamydia and gonorrhea
should also be carried out (Ball, et al 2015).
Blood Tests – Lab drawing will identify HIV / antigen in the blood that could remove HIV. This
patient has more than one confirmed girlfriend that puts him at risk and is sexually active. The
CDC advises that anyone aged 13 to 64 should be screened for HIV at least once in the sense of
normal healthcare. The lack of signs of infection, but with positive serological tests, is
characterized by latent syphilis (Henao-Martínez & Johnson, 2014).
Urine Specimen – Chlamydia and gonorrhea may be removed from a urine test. Chlamydia
trachomatis and Neisseria gonorrheae (gonorrea) are frequently screened concurrently, despite
the related signs and symptoms of infections due to these two bacteria (Henao-Martínez &
Johnson, 2014).
Differential Diagnosis
Genital Warts: Condyloma acuminatum is a papilloma and is also known as Condyloma
acuminatum. Invasive carcinomas are not progressionable and every attempt must be made to
distinguish them from condylomata lata, which is a flat secondary syphilis papule (Holland,
2018). Genital warts can be pruritous, are not symptomatic but can be felt and painful depending
on where. Visual inspections are commonly treated, but the differential diagnosis may be
confirmed using a biopsy (Holland, 2017).
Chancre– is a syphilis-related skin lesion. Primary chancers are typically strong, rund, low, and
painless and grow where bacteria of Treponema pallid reach the body. This occurs in or near the
vagina, the bladder, the rectum, or in or around the mouth. The chancre lasts from 1 to 5 weeks
and is treated free (Dains, 2016).
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.
Henao-Martínez, A. F., & Johnson, S. C. (2014). Diagnostic tests for syphilis: New tests and new
algorithms. Neurology. Clinical practice, 4(2), 114–122.
Holland, K. (2017). What causes vaginal skin tags and how are they treated. Healthline.
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