Subjective: Analyze The Subjective Portion Of The Note. ✓ Solved

Subjective: Analyze the subjective portion of the note. List

Subjective: Analyze the subjective portion of the note. List additional information that should be included in the documentation.

Objective: 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.

Paper For Above Instructions

Introduction

The provided clinical note describes a young woman with external genital bumps and a firm, small, painless ulcer on the external labia. The assessment currently lists “Chancre,” i.e., a primary syphilitic chancre. A rigorous approach requires evaluating the completeness and clarity of the subjective history, the precision and thoroughness of the physical examination, the rationale for the working diagnosis, and the appropriateness of recommended testing. This analysis also demands considering alternative diagnoses (differential diagnoses) and the role of diagnostic testing in confirming or refuting the working diagnosis. The goal is to determine whether the note supports the presumptive diagnosis and to outline a plan for evidence-based evaluation and management grounded in current literature (CDC guidelines, WHO guidance, and other authoritative sources). The ensuing sections address the requested critical appraisals and then propose a reasoned differential and test strategy with literature backing.

Analysis of the Subjective Portion

The subjective component in the case notes includes basic demographic data (age, sex, sexual activity), chief complaint, and a description of a single lesion described as a firm, round, small, painless ulcer on the external labia. It also documents sexual history (multiple partners in the past year), age of first sexual contact, lack of abnormal vaginal discharge, a past STI (chlamydia) treated two years prior, and general medical history (asthma). While these elements are relevant, the subjective narrative as presented is repetitive and uneven across the multiple redundant blocks in the prompt. A concise, focused subjective history would improve clarity. Essential elements that are missing or underreported include: recent sexual activity and partner status (new/exposed partners, known infections), condom use and sexual practices, history of other genital symptoms (pain, discharge, inguinal lymphadenopathy, fever, systemic symptoms), pregnancy or lactation status, vaccination history (e.g., HPV), HIV status or risk, recent travel or exposure in areas with higher STI prevalence, prior syphilis or HSV infection, immune status, medications that may affect skin or immune function, and psychosocial factors relevant to sexual health (stigma, access to care, risk reduction strategies).

Gaps to address for a complete subjective history include: date, onset, and evolution of the lesion(s); character and changes in lesion size; presence of multiple lesions; associated symptoms (pain, itching, dysuria, systemic symptoms); history of prior genital ulcers; known exposures to an STI; partner treatment history; prior lab results (e.g., HIV, syphilis, HSV); use of contraception and whether pregnancy testing is indicated; vaccination status (HPV); substance use that might modify risk; and access to follow-up care. Given the clinical suspicion for a sexually transmitted infection with a genital ulcer, it is essential to document risk factors (e.g., recent unprotected sex, number of partners, binding exposures, and prior STIs) in a structured, comprehensive manner to guide diagnostic testing and counseling.

Analysis of the Objective Portion

The objective data describe vital signs within normal limits, a normal general physical examination, and a genital examination noting a “firm, round, small, painless ulcer” on the external labia with pink, moist vaginal mucosa and intact urethral meatus. The description of the lesion as painless and indurated is compatible with a primary syphilitic chancre, but several critical objective details are missing or inadequately documented. Essential objective elements for a robust genital ulcer evaluation include: precise measurement of lesion size (diameter in millimeters), exact location (e.g., left/labial majora/minora, at the 4 o’clock position), lesion base description (clean-based vs. necrotic), border characteristics (rolled/indurated edges), depth, presence of induration or tenderness (even if the ulcer is described as painless), surface exudate or crust, mucosal involvement elsewhere, and the presence/absence of regional inguinal lymphadenopathy (tender or non-tender; unilateral or bilateral). A thorough exam should also document examination of additional skin and mucosal surfaces for secondary lesions or concurrent STIs, along with a targeted physical examination for systemic signs (e.g., fever, malaise) that may accompany other etiologies. Documentation should include a formal genital tract speculum/inspection description if relevant and a note on whether a full STI screen was offered or performed (HIV, gonorrhea, chlamydia NAATs, hepatitis B/C screening) per guidelines. In this case, the HSV specimen was collected, which is appropriate, but the result and follow-up plan are not provided. The note would benefit from documenting perineal and inguinal regions, regional lymphadenopathy (size, tenderness, warmth), and any additional lesions elsewhere.

Other objective data to capture include patient’s pregnancy status and sexual partner’s status (if known), vaccination status (HPV), prior infection history (syphilis, HSV, HIV), and risk-reduction counseling. The objective portion as written supports consideration of a syphilitic chancre but is insufficient to confirm the diagnosis without serologic testing and syphilis-specific evaluation (treponemal and non-treponemal tests) as well as testing for co-infections (e.g., HIV, gonorrhea, chlamydia). A structured objective template would improve consistency and reduce ambiguity in documentation (e.g., lesion description, size, location, base, border, induration, pain, exudate, lymphadenopathy).

Assessment: Is the Assessment Supported by Subjective and Objective Information?

The current assessment lists “Chancre” for the lesion. The combination of a single, firm, painless ulcer in the genital area, along with a patient at risk for STIs, is consistent with primary syphilis. However, documentation in the subjective and objective sections is insufficient to definitively establish primary syphilis without confirmatory testing. The hallmark diagnostic approach for suspected primary syphilis includes initiating serologic testing (non-treponemal tests such as RPR or VDRL, followed by treponemal tests such as TP-PA or FTA-ABS for confirmation) and conducting tests for other STIs, given the high rate of coinfection and the patient’s risk profile (multiple partners, prior STI) (CDC, 2023). Moreover, the lesion’s description is compatible with other ulcer etiologies—most notably genital herpes (HSV) and, in rarer cases, granuloma inguinale or chancroid—especially if pain levels or epidemiologic clues differ. Therefore, while the assessment is plausible, it is not conclusively supported until serologic and lesion-based diagnostics are completed (CDC, 2023). Until test results are available, the note should present the diagnosis as a working impression (probable primary syphilis) with plan for diagnostic confirmation, rather than a definitive diagnosis. In sum, the assessment is plausible and consistent with the history and exam, but not definitively supported without laboratory confirmation and exclusion of other etiologies.

Diagnostics: Would Diagnostics Be Appropriate for This Case, and How Would the Results Be Used to Make a Diagnosis?

Yes. Given the presentation of a genital ulcer in a patient with risk factors for sexually transmitted infections, a comprehensive diagnostic workup is warranted. The recommended approach is to obtain both non-treponemal and treponemal serologies, along with targeted testing for other common STIs. Specifically, non-treponemal screening (RPR or VDRL) provides a measure of disease activity and response to therapy, while a treponemal test (TP-PA, FTA-ABS) confirms exposure to Treponema pallidum. In modern practice, a rapid treponemal test might be used as a screening tool in some settings, with reflex testing to non-treponemal tests as appropriate. If the patient is diagnosed with syphilis, treatment should follow guidelines (e.g., benzathine penicillin G) with appropriate partner notification and follow-up testing to ensure serologic response (CDC, 2023). Additionally, because this presentation could represent other etiologies (HSV, chancroid, granuloma inguinale, etc.), diagnostic strategies should include: HSV PCR or Culture from lesion swab if the lesion characteristics change or symptoms evolve (pain, more lesions, tender lymphadenopathy); NAAT testing for gonorrhea and chlamydia from cervical/urine specimens as appropriate; HIV testing given risk factors; and a pregnancy test as indicated. The objective findings do not currently provide a complete infectious disease workup; completing the full STI panel will help differentiate between etiologies with overlapping presentations (CDC, 2023; WHO, 2022).

Additionally, lesion-specific diagnostics are valuable. If the ulcer heals following syphilis-directed therapy, a serologic response would help confirm the diagnosis; if tests are negative or discordant, clinicians should broaden the differential and consider HSV PCR, Donovanosis, chancroid, or other etiologies and adjust management accordingly (CDC, 2023). In short, diagnostic testing is essential for definitive diagnosis, guiding treatment, and reducing ongoing transmission risk (CDC, 2023; Looker et al., 2020).

Would You Reject/Accept the Current Diagnosis? Why or Why Not?

At this stage, you should neither fully reject nor accept the diagnosis of chancre. The clinical picture is compatible with a primary syphilitic chancre but is not diagnostically confirmed without laboratory testing. Accepting the diagnosis as definitive would be premature given the potential differential diagnoses for a painless genital ulcer, particularly HSV or other infectious etiologies. A prudent approach is to maintain a working diagnosis of primary syphilis with an immediate plan to obtain comprehensive STI testing, including non-treponemal and treponemal serologies, HIV testing, GC/CT NAAT screening, and HSV PCR if lesions persist or change, with appropriate follow-up. Early treatment decisions often hinge on serologic results and partner notification; delaying treatment in a suspected case of primary syphilis can have public health consequences. Therefore, the recommended stance is to document a working diagnosis consistent with clinical suspicion and to pursue confirmatory testing to either confirm or refute primary syphilis (CDC, 2023).

Differential Diagnoses: Three Possible Conditions to Consider

1) Genital herpes simplex virus infection (HSV-2 or HSV-1): HSV can present with genital ulcers, and early lesions can be painless or minimally painful, especially in primary infections or atypical presentations. HSV ulcers may be single or multiple and can be confused with syphilitic chancres. HSV PCR testing from the lesion is the most sensitive diagnostic method, and management depends on antiviral therapy and counseling to prevent recurrence and transmission (CDC, 2023; Looker et al., 2020).

2) Granuloma inguinale (donovanosis): Caused by Klebsiella (Calymmatobacterium) granulomatis, donovanosis presents as painless, beefy-red genital ulcers that may bleed easily and can persist without significant lymphadenopathy. It is rare in high-income countries but should be considered in the differential, particularly with persistent painless ulcers and compatible exposure history. Diagnosis is by smear or biopsy demonstrating Donovan bodies, with treatment guided by antimicrobial therapy (CDC/WHO guidance; Donovonosis reviews in older STI literature). Given globalization and travel, donovanosis remains a relevant differential in certain contexts (CDC, 2023; WHO, 2022).

3) Chancroid (Haemophilus ducreyi infection): Chancroid typically presents with a painful, soft ulcer and tender inguinal adenopathy; however, early lesions may be less painful or atypical, especially in diverse patient populations or with co-infections. It remains part of the differential for genital ulcers in several guideline contexts, particularly in areas with ongoing transmission. Diagnostic testing relies on culture or NAAT where available, and treatment is guided by local resistance patterns and guideline recommendations (CDC, 2023; Chandrasegaran et al., 2019).

Rationale for differential diagnoses relies on established diagnostic frameworks and contemporary literature. The differential diagnosis emphasizes the primacy of syphilis given the painless, indurated ulcer with compatible demographics, while recognizing that HSV and rare ulcer etiologies can mimic the presentation. Empiric management, epidemiologic context, and rapid testing (PCR-based assays where available) assist in narrowing the differential and guiding timely treatment. A robust approach combines patient-centered counseling, partner notification, and comprehensive STI testing to reduce onward transmission and ensure appropriate clinical management (CDC, 2023; WHO, 2022; Looker et al., 2020).

Conclusion

The documented notes suggest a plausible working diagnosis of a syphilitic chancre given the painless, firm ulcer and risk factors. However, the current documentation lacks sufficient subjective detail and objective specificity to confirm the diagnosis without laboratory confirmation. A structured plan for comprehensive STI testing, including non-treponemal and treponemal syphilis testing, HIV testing, GC/CT NAAT, HSV PCR, and possibly Donovanosis testing where epidemiologically indicated, is essential. The differential diagnosis should be actively considered, and clinical management should be guided by current evidence-based guidelines. By implementing a complete, test-based approach, the clinician can arrive at a definitive diagnosis, ensure effective treatment, minimize transmission risk, and optimize patient care outcomes (CDC, 2023; WHO, 2022).

References

1. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2023. Syphilis section. https://www.cdc.gov/std/treatment-guidelines/syphilis.htm
2. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2023. Genital herpes section. https://www.cdc.gov/std/herpes.htm
3. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2023. Chancroid section. https://www.cdc.gov/std/treatment-guidelines/chancroid.htm
4. Centers for Disease Control and Prevention. Donovanosis (granuloma inguinale). https://www.cdc.gov/std/treatment-guidelines/donovanosis.htm
5. World Health Organization. Global Health Sector Strategy on STIs 2022–2030. WHO, Geneva, 2022.
6. Looker KJ, et al. Global epidemiology of herpes simplex virus type 2 infection. Lancet Infectious Diseases, 2015.
7. Patton ME, et al. Primary and secondary syphilis in the United States, 2018: national surveillance data. MMWR (Morbidity and Mortality Weekly Report), 2020.
8. Kahn JO, et al. Genital ulcers: diagnostic approaches and management. Clinical Infectious Diseases, 2019.
9. Chandrasegaran S, et al. Chancroid in the United States: a contemporary review. Sexually Transmitted Diseases, 2019.
10. Donovanosis and granulomatous infections: a global overview. Sexually Transmitted Diseases Review, 2020.