Special Examinations—Breast, Genital, Prostate, and Rectal GENITALIA ASSESSMENT
Week 10: Special Examinations—Breast, Genital, Prostate, and Rectal GENITALIA ASSESSMENT 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 states 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, neg McBurney •Diagnostics: HSV specimen obtained Assessment: Chancre
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