Lab Assignment: Assessing the Genitalia and Rectum

Lab Assignment: Genitalia and Rectal Assessment of a Young Female Adult with a Raised Painless Vulval Genital Lesion

Sexually transmitted infections (STIs) are a common diagnosis in the United States between both males and females. One of the most important presentations of these STIs is a genital lesion which may be ulcerated or not. The genital lesion may also be either painful or not. Differentiation of the characteristics of the presenting genital lesion is at the root of making a correct diagnosis. It is however important to remember that there are many STIs that present as genital lesions. Lab Assignment: Assessing the Genitalia and Rectum. Even amongst those that present as painless lesions, there are several possibilities to choose from. Because of this alone, STIs presenting as genital lesions are a diagnostic minefield that must be treaded carefully with a keen eye on all the possible differential diagnoses. Patient AB in the episodic SOAP note in question is a young 21 year-old mother of three children who presents with a chief complaint of a genital lesion that is painless but “bumpy”. It is not accompanied by any discharge but feels rough. She admits to a history of previous chlamydia that she was treated for two years ago. She fits the high risk population demographic that is experiencing a scourge of STIs (Shannon, & Klausner, 2018). She particularly admits to having had sex with more than one partner in the past one year. This paper is about analyzing the accompanying episodic SOAP note documentation on this patent and filling in the missing information as well as agreeing with or disagreeing with the stated assessment. The paper will also list the most likely differential diagnoses in the order of likelihood.

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Subjective Assessment of Patient AB

The documentation in the accompanying SOAP note for patient AB shows that it has correctly included the chief complaint, the history of presenting illness by way of the OLDCARTS mnemonic, current medications, allergies, past surgical history, past medical history, social history, and family history. Lab Assignment: Assessing the Genitalia and Rectum. It has however omitted the all important review of systems that is crucial in the subjective assessment of any patient (Ball et al., 2019). This is what is missing and needs to be included in that incomplete documentation as follows:

Review of Systems or ROS

General: The patient reports no fever, fatigue, or weakness.

HEENT: She has no double vision, blurred vision or any other problem with vision. She also does not report any hearing loss or otorrhea. She denies having a sore throat and also denies rhinorrhea or sneezing.

Integumentary: She reports no skin rash, dermatitis, eczema, or itchiness.

Gastrointestinal: She denies diarrhea, vomiting, or nausea. Her bowel movements are regular. She reports having her latest bowel movement on the morning of the visit.

Cardiovascular: She does not report any palpitations or chest pain of any form. She also denies any form of discoloration such as palor in her extremities.

Respiratory: The patient reports no cough, difficulty in breathing, or swelling of the limbs in any form.

Genitourinary: She denies any pain on micturition (dysuria) or any abnormal coloration of the urine. She states that she is not pregnant, with her LMP being on 25/10/2020. However, patient AB reports a painless “bump” on her external genitalia.

Neurological: She does not report any problems with bladder and bowel control. She also denies locomotor ataxia or paraesthesia.

Musculoskeletal: She denies any joint pains or muscle pain/ back pain.

Endocrinologic: She does not drink water excessively or pass urine in large volumes. She denies heat intolerance and excessive sweating under all circumstances.

Lymphatics: She reports no swollen and palpable nodes. She also states that she has never had any splenectomy operation in the past.

Hematologic: She denies bruising, dizziness, or fainting.

Psychiatric: She denies depression or any other form of mental illness.Lab Assignment: Assessing the Genitalia and Rectum.

Allergic/ Immunologic: She denies having any allergies related to the environment, food, or medications. She has also never suffered from allergic conditions such as asthma or rhinitis.

The objective Assessment of Patient AB

The documentation of the objective assessment for patient AB has been done quite well except for two particular shortcomings. One of the missing pieces of information is the general or constitutional assessment of the patient. This should have reported her general appearance and grooming, her level of consciousness or awareness, her mood and affect, her gait, as well as her insight. As expected, however, there is a documentation of her vital signs which show that she does not have a fever (T: 98.6°C or 37.0°C), has a blood pressure of 120/86 mmHg, has a pulse rate of 92, has a respiratory rate of 16, and a body mass index or BMI of 24.2 kg/m² (because her weight is 169 pounds with a height of 5’10”). Appropriately, some selected body systems that are pertinent to the chief complaint (CC) and the HPI have been examined. Of note and importance is the genitourinary system the physical examination of which showed the presence on the external labia of small and painless ulcers that are characteristically round and firm. But the second shortcoming of this documentation is the fact that only one diagnostic test in the form of a herpes simplex virus (HSV) test has been done. Therefore, the missing information that needs to be added to this documentation in the section of objective evaluation is the other diagnostics that are needed to arrive at the various differential diagnoses. These are addressed below as well as their appropriateness for this case and how they are used to arrive at the diagnosis.

Additional Diagnostics Missing from the Objective Section Documentation, their Appropriateness in this Case, and How they are Used to Make a Diagnosis

1. Dermoscopy: This is the observation under a dermatoscope at 10X magnification of scrapings from the lesion. The characteristic findings of a central pore, white or yellow amorphous structures, and rosettes under polarized light will indicate a diagnosis of molluscum contagiosum (Meza-Romero et al., 2019). Microscopy will also help with the diagnosis of granuloma inguinale (Donovanosis) if Donovan bodies are seen under the lens (Macpherson & Cameron, 2017).
2. Rapid plasma reagin (RRR) test or VDRL (venereal disease research laboratory) followed by confirmatory particle agglutination test if reactive. This is the algorithm used to diagnose syphilis by way of serological testing (Ghanem et al., 2020).
3. Nucleic acid amplification testing or NAAT: This particular diagnostic helps in the diagnosis of lymphogranuloma venereum (LGV) which is also a candidate diagnosis. Lab Assignment: Assessing the Genitalia and Rectum. Swabs are taken from the genital lesion, the urethra, the vagina, and rectum for laboratory analysis (Macpherson & Cameron, 2017).
4. Urinalysis: This routine test will help in the establishment or a concomitant urinary tract infection that may also require treatment (Hammer & McPhee, 2018).

Support of the Assessment by the Subjective and Objective Information, and Acceptance/ Rejection of the Current Diagnosis

The subjective and objective information is not fully supporting the current diagnosis of a chancre. As much as a chancre is not painful, it is usually not raised. The current diagnosis is therefore rejected in favor of a diagnosis of molluscum contagiosum (MC). The MC lesion is more in line with the findings in the subjective and objective assessments. This lesion is usually painless, raised, and bumpy (Meza-Romero et al., 2019).

Three Possible Differential Diagnoses

1. Syphilis: The syphilitic chancre is also painless although it is not bumpy (Ghanem et al., 2020).
2. Granuloma inguinale or Donovanosis: The genital lesion in this case is also painless but also has a tendency to bleed easily when touched (Macpherson & Cameron, 2017).
3. Lymphogranuloma venereum: This presents as a small genital papule that may be ulcerated (Hammer & McPhee, 2018; Macpherson & Cameron, 2017).  Lab Assignment: Assessing the Genitalia and Rectum.

References

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9th ed. Elsevier.

Ghanem, K.G., Ram, S., & Rice, P.A. (2020). The modern epidemic of syphilis. New England Journal of Medicine, 382(9), 845-854. https://doi.org/10.1056/NEJMra1901593

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. McGraw-Hill Education.

Macpherson, P.A., & Cameron, D.W. (2017). Lymphogranuloma venereum, chancroid and granuloma inguinale. Infectious Diseases, 585–591.e1. http://dx.doi.org/10.1016/b978-0-7020-6285-8.00064-2 

Meza-Romero, R., Navarrete-Dechent, C., & Downey, C. (2019).  Molluscum contagiosum: An update and review of new perspectives in etiology, diagnosis, and treatment. Clinical, Cosmetic, and Investigational Dermatology, 12(1), 373-381. http://dx.doi.org/10.2147/CCID.S187224

Shannon, C.L. & Klausner, J.D. (2018). The growing epidemic of sexually transmitted infections in adolescents: A neglected population. Current Opinion in Pediatrics, 30(1), 137-143. http://dx.doi.org/10.1097/MOP.0000000000000578

Based on the Episodic note case study:

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. Lab Assignment: Assessing the Genitalia and Rectum. 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)

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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

Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature. Lab Assignment: Assessing the Genitalia and Rectum.

• 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. Lab Assignment: Assessing the Genitalia and Rectum.