Introduction
Patient AB has a history of sexually transmitted infection (STI). She has also had more than one partner in the last twelve months. The last known STI was chlamydia over two years ago. She also has an ulcer on external labia. While the bumps on her genitals are painless, they are a recent event, and says the bumps feel rough. While there several potential diagnoses available, not enough information has been given. A current blood test to screen for STDs/STIs would be beneficial along with hygiene habits like does she shave regularly. This essay is a thought process of what she could have from the collected information.
Subjective Portion of the Note Analysis
Patient stated her bumps are rough feeling and painless. She did not say how many sexual partners she has had. All she said was she had more than one in the last twelve months. She also says she reports no abnormal vaginal discharge. However, additional information to potentially rule out an STI would be if she has painful urination or a burning sensation when she urinates. Additionally, does she have pelvic pain or has had bumps in the past in other areas like the mouth or where she shaves. More information on patient’s personal hygiene habits may provide definitive answers for proper diagnosis.
Objective...
When a woman is sexually active and has a history of STI, she should get a pap smear annually. “The Pap smear is a screening test for cervical cancer. The American Cancer Society recommends an annual Pap test and pelvic examination for all women who are or who have been sexually active, or who have reached age 18 years” (Weber & Kelley, 2010, p. 457). Although no dysplasia was found, potential abnormalities could occur from STIs caused by unprotected sex like HPV (Weber & Kelley, 2010). Therefore, it is important for patient AB to schedule another pap smear as well as a full STD screening.
Patient also includes occasional drinking of alcoholic beverages and an episiotomy scar from a previous childbirth event. Both parents have a history of hypertension and she is borderline overweight for her height. This could mean she does not make appropriate food or lifestyle choices. It may contribute to discovering what is wrong with her. For example, the ulcer on her labia or the bumps could be a sign of Herpes.
Her lifestyle could contribute to stress that could exacerbate her condition. Stress can be associated with the exacerbation of clinical symptoms of Herpes simplex viruses…
