Genitalia Assessment

Subjective Analysis and Additional Information to Include in the Documentation

In this portion, there needs to be more information on the patient’s history of present illness (HPI) and her general health history. I would find out more about her sexual activities in the past and just before the appearance of the bumps. The first question I would ask is if the patient uses protection while having sex and the number of sexual partners she has had. The second question would be if she informed her sexual partner when she had Chlamydia and if she still has sex with that partner. To obtain more information on the bumps, I would find out if the patient has recently shaved her genital area or used a new soap, cream, or lotion on the area. It is also important to obtain the patient’s surgical history that includes obstetric history. After a physical exam, it is established that the patient has an episiotomy scar which can be a result of child birth as she has had three children (Dains, Baumann, & Scheibel, 2016).

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Objective Analysis and Additional Information to Include in the Documentation

The objective part of the SOAP note needs extra details in the physical examination of the external genitalia to match the subjective symptoms; the patient findings on the external labia are positive hence the need for more details like internal palpation to look for other symptoms such as fistula and polyps. The labia need to be palpated for symmetry of swelling, color, irritation, and inflammation. Unilateral labia irritation or swelling can be an indication of Bartholin gland infection; to properly assess for infection, there needs to be milking of the Skene gland. Since vaginal infections can easily transfer to the rectum or the anus, due to their close proximity, it is important to perform a full examination of them. The patient has had multiple sexual partners over a span of one year; therefore, it is essential to carry out a complete body, skin, and throat inspection to assess for signs of sexually transmitted infections (STIs) where I would be keen on the mouth, hands, and feet. STIs affect the lymphs, hence there is importance to carry out a lymph and neurological assessment if there is suspicion of an STI (Dains, Baumann, & Scheibel, 2016).

The subjective information mostly supports the assessment as out of the information, we find out more about what could be the cause of her bumps. For example, she started having sex at an early age, it is also worth noting that she has three children at 21 years; this means that she has had a child every year since she was 18. Having children close together exposes to health risks such as inflammation of her genital tract which occurs during pregnancy and needs to heal in between pregnancies. The patient also has a history of an STD, Chlamydia in addition to having multiple sexual partners within a year. Also she has not had a pap smear for three years which she should have considering her active sexual life (Wagenlehner, Brockmeyer, Discher, Friese, & Wichelhaus, 2016).

Would diagnostics be appropriate for this case and how would the results be used to make a diagnosis? 

Extra diagnostic testing will be helpful in narrowing down the probable differential diagnosis.  A Rapid Plasma Regain (RPR) will test for syphilis in addition to the specimen of HSV collected; also Venereal Disease Research Laboratory (VDRL) and Treponema pallidum test should be performed. In case of positive results, more tests should be done to determine the stage of each disease. As the patient has a history of STDs and her active sexual life that involves more than one partner, it would be appropriate to do a HIV, Chlamydia, and gonorrhea test. If these tests come out negative, then the bumps will have to undergo a biopsy to rule out cancer of the vulva and Human Papilloma Virus (HPV) (Wagenlehner, Brockmeyer, Discher, Friese, & Wichelhaus, 2016).

Differential Diagnosis

The correct diagnosis out of both the subjective and objective information is whose symptoms include painless indurated ulcers (chancre), which are solitary, with non tender bilateral lymphadenopathy. Syphilis is transmitted through unprotected sexual intercourse with an infected person and it is mostly common in people who have more than one sexual partner. Syphilis damages an individual’s neurological, hepatic, and muscoskeletal systems therefore there is need to treat it as soon as a diagnosis is made. Other differential diagnoses for the information provided include vulva cancer, Bartholin cyst, and Genital Herpes infection (World Health Organization, 2019).

Cancer of the vulva accounts for four percent of all cancers that affect the female reproductive organs. It manifests as a painless bump on the vulva and it may accompany pruritis due to vaginal irritation; it is easy to confuse it with genital herpes or syphilis hence the need for more tests that may include a biopsy on the bumps. Vulva cancer is more common in women over 50 years and one of its major symptoms is a change in color of the skin and feel of the vulva (World Health Organization, 2019).

Genital herpes is caused by the herpes simplex virus and it is transmitted through skin contact with an infected person through sex and kissing. A person can have the virus without the sores hence can transmit it to another person in case of skin to skin contact. The first signs of genital herpes are genital itching, discomfort, burning, flu like symptoms, and fever; other symptoms include swollen lymph nodes and sores or blisters. A HSV and HVC test is done to diagnose genital herpes. When an individual has genital herpes, they become more susceptible to STIs, meningitis and can infect babies leading to brain damage, blindness, and even death (Wagenlehner, Brockmeyer, Discher, Friese, & Wichelhaus, 2016).

A Bartholin cyst is a cyst that forms of the Bartholin glands on both sides of the vagina close to the labia. The glands generate lubrication that moisturize the vagina and keep the PH of the vagina balanced. When the Bartholin gland’s ducts block, an infection occurs that results in formation of cysts that are not painful if not infected. They are more common in women between the age of 20 – 30 years and the chance of getting a Bartholin cyst decreases as the woman ages. The physical exam findings are not consistent with a diagnosis of Bartholin cyst as they are filled with fluid in contrast to the patient’s bumps which are painless and rough (Wagenlehner, Brockmeyer, Discher, Friese, & Wichelhaus, 2016).


Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Wagenlehner, F. M., Brockmeyer, N. H., Discher, T., Friese, K., & Wichelhaus, T. A. (2016). The Presentation, Diagnosis, and Treatment of Sexually Transmitted Infections. Deutsches Arzteblatt international, 113(1-02), 11–22. doi:10.3238/arztebl.2016.0011

World Health Organization. (2019, February 28). Sexually transmitted infections (STIs). Retrieved from

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