Analyze An Episodic Note Case Study For This Assignme 407004

Analyze an Episodic Note Case Study That for This Assignment

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, which physical exams and diagnostic tests should be conducted, and formulate at least five differential diagnoses with several possible conditions. Pretend that this is an actual patient and provide as much detail as possible.

Paper For Above instruction

The case involves a 21-year-old woman presenting with external genital bumps, which are painless and feel rough. Her history reveals recent discovery of bumps that have been present for about a week, with no associated vaginal discharge or other systemic symptoms. She reports being sexually active with multiple partners over the past year, including starting sexual activity at age 18. Her last Pap smear was three years ago and was normal, and she has a history of chlamydia infection two years prior for which she was treated. Her medical history includes asthma, and she currently uses Symbicort inhaler. Her family history includes hypertension and GERD. She denies tobacco use and uses alcohol occasionally. She is married with three children.

In evaluating this patient, a comprehensive history should include questions about the onset, duration, and any changes in the bumps, associated symptoms such as pain, itching, or discharge, sexual activity, condom use, history of sexually transmitted infections (STIs), and prior gynecological examinations. It is vital to determine if she has other symptoms such as discomfort during urination or systemic symptoms, as well as any history of similar lesions. Her sexual history, including partner history and condom use, helps assess STI risk. Also, asking about prior treatments or similar episodes provides context.

Physical examination should focus on inspecting the external genitalia for characteristics of the lesions—size, shape, number, and distribution—and assessing surrounding tissues for erythema, ulceration, or edema. Palpation may determine if the lesions are fixed or movable. Examination of the vaginal mucosa, urethral meatus, perineum, and inguinal lymph nodes can provide clues about the etiology. An assessment of the patient’s overall health status and any other skin or mucous membrane lesions is also important. Notably, the observed firm, round, painless ulcer on the labia raises suspicion for an infectious or neoplastic process.

Diagnostic testing should include obtaining a specimen for herpes simplex virus (HSV) testing, as well as considering testing for other STIs such as gonorrhea and chlamydia, using nucleic acid amplification tests (NAATs). A moist lesion sample can also be sent for a Tzanck smear or culture to detect HSV. If indicated, a biopsy of the lesion may be performed to rule out other conditions like vulvar intraepithelial neoplasia or malignancy. Additional evaluations might include serologic tests for syphilis (VDRL or RPR) if syphilitic chancres are suspected, especially given the painless ulcer presentation.

Based on the presentation of a painless, firm, round ulcer, the differential diagnosis should include:

• Syphilitic chancre – associated with primary syphilis, characterized by a painless, indurated ulcer.
• Herpes simplex virus (HSV) infection – typically presents with painful vesicles or ulcers, but can sometimes be painless.
• Lymphogranuloma venereum – causes small, painless ulcers that can go unnoticed.
• Vulvar carcinoma – especially in a young woman with persistent lesions; although less common, it must be considered.
• Trauma or folliculitis – secondary to irritation or infection, presenting as benign bumps or ulcers.

Assessing this patient's lesions involves correlating her history with physical exam findings and laboratory results to reach an accurate diagnosis. Given the characteristics, a primary suspicion of syphilis remains high. Confirmation through serologic testing, along with HSV testing, will guide appropriate management. Counseling about safe sexual practices and notification of the patient's partners are essential components of care. Follow-up to monitor lesion resolution and review test results will help confirm the diagnosis and initiate treatment if needed.

References

• Ball, J. W., 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 Mosby.
• Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). Elsevier Mosby.
• Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). F. A. Davis.
• Centers for Disease Control and Prevention. (2019). Sexually transmitted diseases (STDs). https://www.cdc.gov/std/default.htm
• Cucci, E., Santoro, A., DiGesu, C., DiCerce, R., & Sallustio, G. (2015). Sclerosing adenosis of the breast: Report of two cases and review of the literature. Polish Journal of Radiology, 80, 122–127. https://doi.org/10.12659/PJR.892706
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• Westhoff, C. L., Jones, H. E., & Guiahi, M. (2011). Do new guidelines and technology make the routine pelvic examination obsolete? Journal of Women’s Health, 20(1), 5–10.