Assessment of Genitalia and Rectum in 21yo Student: Clinical Findings

Introduction

Genitalia and rectum assessment try to take a view on abnormalities in a patient associated with genital areas, for example, Virginal and rectum. This paper, therefore, tries to examine problems associated with Genitalia and rectum in a clear analysis and findings from a patient in a clinical setting. A 21-year-old student reported to a clinic having been infected in her genital areas with swollen bumps which she doesn't know the reasons form bumps occurrence for they are painless.

Is your time best spent reading someone else’s essay? Get a 100% original essay FROM A CERTIFIED WRITER!

Save 25%

Subjective Part

Having been keenly observed and clearly heard from the 21year old student experiencing a genital problem on bumps swelling. It has been realized that the student has been having some sexual practices in previous year different partner. The client was able to explain herself correctly giving out a clear report on her problem though not being sure on when it started. She put is a good indication that the bumps were painless and at the same time, they were rough. Although it noted that she had once had an STI (chlamydia) 2 years ago. Based on her social life history she's married having a boy and two girls. Based on this information it is recommended that the lady could have added on any other sexual infection that she had initially faced or where she had any genetic infection from parents that may necessitate her problem.

Objective Part

Various observable measures were taken and the results were as follows, "Temp 98.6; BP 120/86; RR 16; P 92; HT 5'10"; "WT 169lbs Heart: RRR, no murmurs. Lungs: CTA chest wall symmetrical". The distribution pattern of the air was normal and at the same time genital swelling or masses was not there. No discharge on urethral but virginal posed the following features of pink mucosa with moist and rugae present.

It also had around small and painless ulcer on the external labia. Archana 2014, added that MRI scan should be conducted which is a technique for investigating uterine abnormalities, swollen lymph nodes, and weight loss, mouth ulcer or any other effects on the body other than vaginal genitalia symptoms.

Assessment Part

The most likely diagnosis was Chancre because of the painless and rough bumps on the bottom. The presence of pink mucosa with moist and rugae and round small and painless ulcer on the external labia were also signs that favor identification of Chancre infection which is syphilis growing disease. The diagnosis is therefore acceptable as it portrays the likelihood of the presence of chancre.

Differential diagnosis taken, Chlamydia was ruled out because the bumps were painless and no discharge from the vagina which is not is sign and symptoms (Lanjouw, 2015). Genital herbs ruled out too because it involves pain itching and small sores which were not seen in the physical exam. Human papillomavirus (HPV) ruled out since warts weren't observed in the genital and the surrounding skin (Musen, 2014). Gonorrhea is also ruled out since most of its symptoms include great discharge in vaginal and accompanies the pain. On the other hand, evidence has been found that sexually transmitted diseases are may be associated with mouth to genital contact with what is known as Oral-genital sex (Carbone, 2016). It is one of the conditions that should be considered to the patient. Fever is another factor that may be considered as it may be a differential symptom that may differentiate one infection from another. Lastly, Vaginal bleeding may and pain during sex is necessarily included as a condition for differential diagnosis for this patient.

Reference

Lanjouw, E., Ouburg, S., De Vries, H. J., Stary, A., Radcliffe, K., & Unemo, M. (2016). 2015 European guideline on the management of Chlamydia trachomatis infections. International journal of STD & AIDS, 27(5), 333-348. Retrieved from https://journals.sagepub.com/doi/abs/10.1177/0956462415618837

Musen, M. A., Middleton, B., & Greenes, R. A. (2014). Clinical decision-support systems. In Biomedical informatics (pp. 643-674). Springer, London. Retrieved from https://link.springer.com/chapter/10.1007/978-1-4471-4474-8_22

Archana, B., Prasad, S., Beena, P., & Okade, R. (2014). Making a serological diagnosis of syphilis more accurate. Indian Journal of Sexually Transmitted Diseases and AIDS, 35(1), 70 Retrieved from http://search.proquest.com/openview/b54455c0982dd464b5e09c4dbf08f7c2/1?pq-origsite=gscholar&cbl=226503

Carbone, P. N., Capra, G. G., & Nelson, B. L. (2016). Oral secondary syphilis. Head and neck pathology, 10(2), 206-208. Retrieved from https://link.springer.com/article/10.1007/s12105-015-0623-3