Introduction
Unique examination of the breast, genitalia, prostate, and rectum is a sensitive issue in the medical field that requires critical attention. To accurately assess and provide quality care, healthcare professionals must conduct a practical physical exam and critically analyze subjective and objective data (Ball et al., 2021)
Subjective Data
Subjective data refers to the information that the patient or the family members reports. It is also considered a symptom because it hints at meeting the needs. The health caregiver should be sensitive during data collection and every detail pursued following its relevance and importance to the chief complaint (Sullivan, 2019)
The 21-year-old white female patient reports chief complaints of having bumps on the genital area that feel rough and are painless, although unsure of when the bumps started. She gave her sexual history, where she had her first sexual contact when she was 18 years old and has had more than one sexual partner in the past year. She reports normal vaginal discharge, but two years ago, she had chlamydia, which was treated, and the dose was completed. She did a pap smear three years ago that showed the expected results, as no dysplasia was found. The 21-year-old has a past medical history of asthma, reports no known drug allergies and is currently on Symbicort 160/4.5mcg. On the family history, there is no history of cervical or breast cancer, the father has a history of hypertension, and the mother has both hypertension and gastroesophageal reflux disease (GERD). She is married and has one girl and two boys, an occasional ETOH but denies tobacco use.
In addition, the subjective data should include the following information. How the bumps started, give the menstrual history, i.e., amenorrhea, any abnormal vaginal bleeding like intermenstrual, and history of sexual intercourse such as pain during coitus and libido. Other accompanying signs and symptoms besides the painless sore could have been asked to make a clinical judgment accurately—for example, any headaches, fatigue, weight loss, fever and swollen lymph nodes.
Objective Data
The objective data is obtained from physical examination and observations on the patient, diagnostic and laboratory tests, and measurements such as temperature. Objective data is what the caregiver can smell, see, taste, touch, and even feel.
On the objective data, the vital signs are all within the normal ranges: Temp 98.6, BP 120/86, RR 16, P 92, HT 5’10’, and WT 169lbs. The heart and lungs show normal findings. Regular rate and rhythm (portrays normal cardiac exam), no heart murmurs heard, and the chest wall is symmetrical. On the genital exam, there is normal hair distribution, no swelling or masses, and the urethral meatus is intact with no discharge or erythema. The perineum is intact, and the vagina is moist and pink with reggae, round and small. However, a painless ulcer is noted on the external labia. The abdominal exam shows soft, normoactive bowel sounds, negative rebound, Burney, and murphy. Herpes simplex virus specimen was obtained for the diagnostic test.
More information on the objective data includes the smell of the perineum and vaginal discharge, the presence or absence of blisters and fluid-filled sores to rule out genital herpes, and examination of the buccal cavity for any sores (Lowth, 2019). Other diagnostic tests include; a complete blood count, urine sample test, serologic test for syphilis, and repeat Pap smear test.
The assessment data
From the objective and subjective data obtained, the 21–year–old is assessed to have Chancre. A chancre is a small, firm, round, and painless sore that appears around the genitals, rectum or mouth for a few days to weeks. Chancre, a reddish sore, is the first main sign of syphilis and occurs typically at the portal of entry for the bacteria.
The subjective and objective data collected supports the assessment data (Chancre). On the subjective data, the patient reports having external bumps on the genital area, which she noticed about a week ago, and the bumps are rough and painless. On her sexual history, she is currently married. She had more than one sexual partner in the past year and had a history of chlamydia two years ago but was treated. Her Pap smear exam three years ago showed results, and no dysplasia was seen. The above data reveals a sexually transmitted infection that is the onset of syphilis, whose main early sign is Chancre. From the objective data, the genital exam shows a pos for a firm, round, small, painless ulcer observed on the external labia, indicating a chancre. The herpes simplex virus specimen obtained is to test for and rule out genital herpes disease. In conclusion, the objective and subjective data support the assessment data (Chancre).
Diagnostic tests
Diagnostics would be appropriate for this case to judge the exact problem critically. For instance, a complete blood count test would indicate the presence of infection in case of elevated white blood cells. A pap smear is a test that detects pre-cancer cases in the cervix and any chances of dysplasia. A pap smear is done after three years for women aged 25-65. The HSV sample test is used to diagnose genital herpes infection and rule it out, as in this case. Additionally, a serologic test for syphilis is vital to confirm the presence of the onset of syphilis because Chancre is an early sign and symptom of syphilis.
The differential diagnosis for the patient
- Granuloma inguinale– a painless ulcerative lesion in progress but presents with no regional lymphadenopathy. The lesions in granuloma inguinale easily bleed because of high vascularity.
- Condyloma acuminatum- refers to warty lesions that present around the perineum as clusters and easily spread around the genitalia.
- Lymphogranuloma venerum- presents as a painful genital ulcer/papule or femoral lymphadenopathy and is usually self-limiting.
- Candidiasis is a genital condition characterized by itching, redness, and discomfort in the affected area.
- Trichomonas vaginalis- is a sexually transmitted infection that presents with swelling and itching around the vagina despite vaginal discharge.
Differential diagnosis
The current diagnosis (Chancre) is correct based on the subjective and objective data presented. A chancre is a reddish, firm, round, small painless sore that majorly appears around the perineum or the buccal cavity and is transmitted sexually. The data obtained describes the presence of Chancre on the external labia.
Differential diagnosis aids in clinical reasoning hence coming up with assessment data (Dains et al., 2019). Differential diagnoses for syphilis chancre include herpes simplex, furuncle, and chancroid.
- Herpes simplex and syphilis chancre are characterized by sores around the mouth, rectum or genitals, but they are significantly different. Herpes appears as fluid-filled sore or blisters, small in diameter, itchy and painful. The blisters appear as a group, clear after a couple of weeks and usually leave scarring after healing. Herpes may be accompanied by trouble peeing, pain/discomfort around the genitalia, itching and a burning sensation during micturition. Lastly, there is no cure for genital herpes, but medication can relieve the severity. Syphilis chancre, on the other hand, occurs as a single painless sore and does not bring discomfort to the genitals.
- Furuncles (Boils) are purplish or reddish bumps that are painful and pus-filled. They mostly appear on the buttocks, thighs, armpits, face, and back of the neck. Furuncles increase in size as the bump fills and develops a yellow-white tip that finally ruptures and drains the pus; this is not the case with Chancre.
- Chancroid, a sexually transmitted infection, appears as one or more tender genital ulcers that are curable but highly contagious. Regional lymphadenopathy is significant for chancroid. Unlike Chancre, chancroid typically grows to significant sizes and is very painful.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2021). Seidel’s Guide to Physical Examination-E-Book: An Interprofessional Approach. Elsevier Health Sciences.https://www.amazon.com/Seidels-Guide-Physical-Examination-Interprofessional/dp/0323481957
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced Health Assessment & Clinical Diagnosis in Primary Care-E-Book. Elsevier Health Sciences.https://www.elsevier.com/books/advanced-health-assessment-and-clinical-diagnosis-in-primary-care/dains/978-0-323-55496-1
Lowth, M. (2019, June 20). Genitourinary History and Examination (Female). Patient. https://patient.info/doctor/genitourinary-history-and-examination-female
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis. https://books.google.co.ke/books?hl=en&lr=&id=SaJmDwAAQBAJ&oi=fnd&pg=PP1&dq=Sullivan,+D.+D.+(2019).+Guide+to+clinical+documentation+(3rd+ed.).+Philadelphia,+PA:+F.+A.+Davis&ots=zAbqExda1V&sig=5ZYzrgu0klJ_Tvf48sAhOy2oBjo&redir_esc=y#v=onepage&q=Sullivan%2C%20D.%20D.%20(2019).%20Guide%20to%20clinical%20documentation%20(3rd%20ed.).%20Philadelphia%2C%20PA%3A%20F.%20A.%20Davis&f=false
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