Posted: July 17th, 2022

Episodic note case study

For this assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

Review the following Episodic note case study:

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 external
bumps 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 the
past year. Her initial sexual contact occurred at age 18. She reports no abnormal
vaginal discharge. She is unsure how long the bumps have been there but
noticed them about a week ago. Her last Pap smear exam was 3 years ago, and
no dysplasia was found; the exam results were normal. She reports one sexually
transmitted infection (chlamydia) about 2 years ago. She completed the
treatment 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. Urethral
meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa
pink and moist with rugae present, pos for firm, round, small, painless ulcer noted
on external labia
• Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, negMcBurney
• Diagnostics: HSV specimen obtained

– Free Essay Sample
Assessment:
Episodic Note Analysis
Name
Academic Institution

Episodic Note Analysis
Subjective Portion
The subjective portion of the note shows that the patient has external, painless but rough bumps on the genital area. The patient indicates she has no known allergies which show the bumps could be a result of bacterial or viral infection. The viral infection could be a result of engaging sexually active with multiple partners (Ferrari et al., 2018). She also had chlamydia two years ago although it was treated. The patient is suffering from asthma and is currently on medication. Asthma is less likely to cause the bumps in the genital areas. Therefore, additional information is required to ensure a proper diagnosis is carried out about the patient’s condition.
The additional information required for proper diagnosis is meant to clarify the medical history of the patient. It is important to confirm the history of other STIs such as herpes and gonorrhea and their respective medication. It is also crucial to know if the patient has any history of skin disease of chickenpox. The patient should also disclose if they have any history of vaginal injury or surgeries (Dains, Baumann & Scheibel, 2018). The sexual reproductive history of the patient is also critical. For instance, it is important to know if the patient has engaged in anal or oral sex. Additionally, it is critical to know if they have a homosexual partner and the health condition of the sexual partners. It is also important to confirm if the patient is taking any medication or supplements. Their personal history and living conditions are also important.
Objective Portion
The objective information provided shows that the patient’s conditions are in the optimal range except for the genitals. The vital signs including temperature, blood pressure, and respiratory rate show no abnormality. However, objective information is missing critical details. For instance, it is critical to confirm the temperature location and body mass index (Dains, Baumann & Scheibel, 2018). Additionally, there is a need to gather extra information about the genital area which is affected.
The additional information required will include a pap smear to assess the genital area. It is also important to assess uterine size and cervical tenderness. A clinician should also confirm if there is any vaginal discharge, it’s color and whether it has any odor. It is also crucial to palpate to assess inguinal lymphadenopathy, skene glands and palpate Bartholin to check for discharge and tenderness. The assessments should also include a rectal exam to confirm any tenderness, lesions, hemoccult, or masses (Dains, Baumann & Scheibel, 2018). The skin should also be assessed to confirm any lesions, scaling or discoloration.
Subjective and Objective Portion
The current assessment is not supported by the subjective and objective information. The reason is that the subjective and objective portions are missing critical details necessary for an accurate assessment. For instance, the reproductive area of the patient should be thoroughly assessed to determine the cause of the bumps (Dains, Baumann & Scheibel, 2018). The medical history of the patient should also be analyzed to determine whether chlamydia was treated effectively or not. The patient also should confirm the health condition of her sexual partners. The health condition will be used to determine whether it is a possible sexually transmitted condition or not.
Diagnostics Tests
Diagnostic tests are necessary due to the suspected STI. The diagnostic tests will be critical in the assessment include tzanck smear, HSV, PCR, rapid test, syphilis serology, scrapping, UA test and serum HCG (Ferrari et al., 2018). The diagnostic tests are important to confirm the presence of viral or bacterial infection. The tests will also help in the assessment by ruling out some conditions such as syphilis (Ferrari et al., 2018). For example, Nucleic-Acid Amplification Tests rapid tests will be critical to assess the presence of gonorrhea and chlamydia. On the other hand, tzanck smear will be used to check for herpes (Wilson et al., 2017). Additionally, it is important to check if the patient is pregnant by carrying out a serum HCG test (Wilson et al., 2017). The test will be critical in the diagnosis. Therefore, diagnostic tests will be critical in the assessment especially in ruling out suspected conditions and narrowing down to one disease.
Diagnosis
I would reject the current diagnosis since the subjective, objective and diagnostic portions do not provide all the necessary information. The diagnosis requires a battery of tests to be carried out to rule out possible conditions that may also cause bumps on the genital areas (Wilson et al., 2017). The medical history of the patient should also be assessed critically to determine the health risks they could be facing.
The three possible conditions that can be considered in the differential diagnosis include syphilis, herpes progenitalis, and herpes progenitalis with asymptomatic chlamydia. The patient is at risk of the three sexually transmitted diseases due to the multiple sexual partners (Ferrari et al., 2018). The conditions will be analyzed and determined using physical examination, medical history, and diagnostic tests. For instance, a serology test will be used to determine or rule out syphilis while tzanck smear will check for herpes. The diagnostic tests are thus critical in assessing the various conditions in the differential diagnosis.

References
Dains, J. E., Baumann, L. C., & Scheibel, P. (2018). Advanced Health Assessment & Clinical Diagnosis in Primary Care E-Book. Elsevier Health Sciences.
Ferrari, R. L., De Andrade, J. C., Chagas, W., Ramos, M. E. B., Freire, N. D. A., Maciel, R. D. M., & Israel, M. S. (2018). Syphilis diagnosis from multiple flat condyloma of the mouth: a case report. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, 126(3), e55.
Wilson, S. P., Vohra, T., Goldberg, J., Price, C., Calo, S., Mahan, M., & Miller, J. (2017). Reliable rapid assay for gonorrhea and chlamydia in the emergency department. The Journal of Emergency Medicine, 53(6), 890-895.

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