Special Examinations-Breast, Genital, Prostate, and Rectal
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Additional Subjective Data
During the physical examination, the nurse should conduct a more detailed analysis of the symptoms to determine their size, shape, color, and pattern. The patient should be asked to give a more detailed description of her symptoms. The patient will be asked whether it is the first time she is experiencing the signs, or she has had them previously. If it is not the first time, she will be asked to describe when she last experienced them and the medication used to manage the previous episodes. The nurse should enquire whether the patent has noticed the bumps in any other body part other than the genitals, such as the skin (Ball, Dains, Flynn, Solomon & Stewart, 2014).
Sometimes bumps in the genitourinary tract are associated with other general conditions. Therefore, the physician should check for other conditions such as the presence of skin rash, recent weight loss, loss of body hair, a fever, sores on the anus, dysuria, fatigue, and muscle aches.
The patient will be asked whether any of her sex partners had had the symptoms, what she was doing when she noticed the bumps, and whether her house is infested with parasites such as lice or scabies. The nurse should also enquire whether the patient has experienced any itching or burning currently or before noticing the bumps.
It will also be essential to determine whether the bumps have looked the same all week or their appearance has changed and whether they are spreading, present 100% of the time, or do they come and go. The patient should report if she is aware of anything that aggravates the bumps or decreases the number of cracks and whether she has tried home remedies and what outcomes were achieved.
The patient should be asked about exposure to genital bump risk factors such as douching, use of scented and medicated genital soaps, lotion, and sanitary pads.
Under the past medical history, the patient should be asked about any recent surgeries or procedures requiring anesthesia, recently started medications and the drugs that were prescribed for her previous chlamydia infection. The physician should inquire whether the patient has any skin conditions, allergies, a full course of immunization, and the age of asthma diagnosis.
The medical history should also entail the patient’s gynecological history regarding menstrual onset, frequency, duration, volume, date of last menstrual period, contraception use, and HIV status. It helps eliminate hormonal imbalance, pregnancy, and HIV, which could be responsible for genital bumps.
On the sexual history, the patient’s preference for risky sexual practices such as unprotected sex, anal sex, and multiple sexual partners, should be documented t determine the exposure to STD risk factors. The client’s occupational history is very significant in determining exposure to STD risk factors (Westhoff, Jones & Guiahi, 2011).
Additional Objective Data
Documentation of the overall patient’s appearance regarding the level of cleanliness and grooming helps determine the level of body hygiene, which could be a factor in the development of genital bumps.
HEENT exam should also entail throat assessment to check for redness, drainage, edema, enlarged tonsils, cold sores, lesions, and nodal tenderness. It should also entail cervical evaluation to check for enlarged cervical nodes. A mouth examination to check for mouth sores is also essential. These assessments help in determining the presence of viral infection.
The Chest exam should also check for non-labored breathing, enlarged axillary nodes, discharge, and tenderness over the nipples, which could also be signs of viral infection.
In the genito-urinary exam, it would be essential to assess for cervix tenderness, vaginal bleeding, and foul-smelling vaginal discharge. A rectal exam to ascertain any lesions, hemorrhoids, masses, and trauma is also necessary.
Do Subjective and Objective Data support the Assessment?
The patient was diagnosed with Chancre, a highly infectious painless ulcer, which is a primary stage of syphilis. A chancre is a sexually transmitted infection that usually develops over the genital area. In females, chancres can also present over the vagina, anus, or the vulva and take between 3 weeks to 3 months to show after infection.
Subjective data support the diagnosis because the patient reportedly noticed a painless and rough lump over her genital area and reported no vaginal discharge. She also said to be sexually active, have more than one sex partner, which increases her risk of a sexually transmitted infection. Objective data
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