Nursing Assessment
History to be collected from the patient
The patient seeks medical attention due to pimples on her “bottom” according to her. From the complaint, the history that needs to be focused on is the onset of the blisters and the sexual engagements of the patient. Her sexual life can be assessed by enquiring on the sexual partners in the last one month then last 12 months, sexual practices she has engaged in. Being sexually active, the frequency of use and forms of protections they have been using during intercourse to protect themselves from sexually transmitted infections ought to be noted (Centers for Disease Control and Prevention, 2015). History of sexually transmitted diseases and form of family planning method she is using to prevent pregnancy should also be indicated. History of menarche and last menstrual period can be given consideration. Presence of any discomforts during sexual intercourse such as pain, discharge or bleeding is crucial to be included in the history. Itchy feeling around the genitals, pain during micturition and presence of pelvic pain in the recent past should be enquired.
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For the subjective data documented, history of trauma and genital medical surgeries has to be included as one of the causes of genital lesions. Being married, the history of the sexual behaviors of the husband has to be documented to for diagnosis and later management. Additional information should have also included a review of how the severity of condition has affected her normal life operations. The method of delivery of the three babies would be crucial to note. As well as obtaining family history on the chronic illnesses as well as Human Papilloma Infections in the family in case any occurrence.
Physical examinations to be done to the patient
Physical examination is essential in obtaining the objective data concerning the location, appearance, and status of the pimples. It is during the physical assessment that the presence of lesions can be detected. Careful examination of other parts apart from the location of the blisters should be done. Inspection as part of the assessment should be given priority before any attempt to collect the specimen. The positioning of the patient is essential for the evaluation to be adequate. Lithotomy position can be considered.
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Diagnostic tests appropriate for the patient
On top of clinical presentations and findings, diagnostic tests are essential to confirm the diagnosis and eliminate differential diagnoses. In this case, a swab sample from the lesion should be cultured to determine the organism behind the illness (LeGoff, Péré & Bélec, 2014). The cultured cells are then studied under a microscope by a qualified physician before giving a report. A vaginal or urethral swab can also be obtained to determine the causative agent. A blood sample should be collected for a Polymerase Chain Reaction (PCR) blood test to be carried out to determine the DNA of the organism.
Conditions to be considered for differential diagnosis
The following conditions would be regarded as differential diagnoses
- Genital Herpes
- Chancroid
- Granuloma inguinale
- Genital warts
- Syphilis
- Molluscum contagiosum
- Lymphogranuloma venereum
Most genital lesions are brought about by the Sexually Transmitted Infections affecting mostly sexually active young adults between 15-24 years. Having multiple sexual partners and engagement in unprotected sex are among the facilitating factors towards contracting this conditions (Williams, Barber & Hollenbach, 2018)….
I would accept the current diagnosis of Genital herpes. It is the most common cause of ulcerations in the genital area or the rectum especially common among young adultswho are sexually active. Some of sores may not be painful while some burst and become painful. In the case of AB the lesions are painless that is why she could not trace the onset.
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References.
Barrell, A. (2017). “What causes female genital sores?.” Medical News Today
Centers for Disease Control and Prevention. (2015). Sexually transmitted diseases treatment
guidelines, 2015. Annals of Emergency Medicine, 66(5), 526-528.
LeGoff, J., Péré, H., & Bélec, L. (2014). Diagnosis of genital herpes simplex virus infection in
the clinical laboratory. Virology journal, 11(1), 83.
Schlafer, D. H., & Foster, R. A. (2015). Female genital system. Jubb, Kennedy, and Palmer’s
Pathology of Domestic Animals,, 3, 358-464.
Williams, E., Barber, C., & Hollenbach, L. L. (2018). PFAPA Syndrome: An atypical Cause of
Genital Ulcers in the Adolescent Female. Journal of Pediatric and Adolescent
Gynecology, 31(2), 212.
