Assessing the Genitalia and Rectum HW 4

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 state: s 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. 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)

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 PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

Assignment: Assessing the Genitalia and Rectum

Patients are frequently uncomfortable discussing with healthcare professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital. Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to accurately assess patients with problems in these areas.

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HW 4: Examining the Genitalia and Rectum

• CC: “I have some pimples on my bottom that I’d like to have looked out.”

• HPI AB, a 21-year-old WF college student, presents with external lumps on her vaginal area to your clinic. She claims that the pimples are painless yet unpleasant. She claims to be sexually active and to have had multiple partners in the last year. At the age of 18, she had her first sexual encounter. She says she hasn’t had any unusual vaginal discharge. She doesn’t know how long the bumps have been there, but she first saw them a week ago. Her most recent Pap smear check was three years ago, and there was no dysplasia discovered; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about