Posted: July 14th, 2022

CC: “I have bumps on my bottom that I want to have checked out.”

GENITALIA ASSESSMENT
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
Assessment:
• Chancre
Review the Episodic note case study provided you for this week’s Assignment.
Based on the Episodic note case study:
Review this week’s Learning Resources and consider the insights they provide about the case study.
Refer to Chapter 3 of the Sullivan resource to guide you as you complete your Lab Assignment.
Search the Walden library or the Internet for evidence-based resources to support your answers to
the questions provided.
Consider what history would be necessary to collect from the patient in the case study. There are no lumps or swelling in the genital region, and the female hair pattern is normal. The urethral meatus is clear of erythema and there is no discharge. Perineum intact. Pink and moist vaginal mucosa with rugae present; positive for a hard, circular, tiny ulcer that is painless and noticed on the external labia.
Abd: mild, normoactive bowel sounds; negative for rebound; negative for murphy’s; negative for McBurney
Obtaining an HSV specimen as part of the diagnostic procedure
Assessment: • Chancre
For this week’s assignment, you will need to look over the Episodic note case study that was provided to you.
According to the case study presented in the Episodic note:
Read through the Learning Resources for this week and think about the insights they bring regarding the case study you’re working on.
As you work through the Lab Assignment, you should use Chapter 3 of the Sullivan resource for direction and Helpance.
Conduct research in the Walden University library or on the Internet to find resources that offer evidence to back up your responses to the questions that have been supplied.
Think about what information about the patient’s past might be required for the case study and acquire that.

Consider what physical exams and diagnostic tests would be appropriate to gather more information
about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the
patient

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