AB: External Bumps on Genital Area With No Abnormal Symptoms - Essay Sample

Introduction

AB, a 21-year-old female student, presents with external bumps on her genital area. She says that the bumps are rough and painless. She is sexually active and has had sexual relations with more than one partner over the past year. She has been sexually active since she was 18 years old. She does not have abnormal vaginal discharge, and she is unsure of the duration of the bumps but noticed them about a week ago. Her last Pap smear test was three years ago where dysplasia was absent, indicating a typical result. She reported having had chlamydia about two years ago. She completed the treatment chlamydia as prescribed.

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Analysis of Subjective Information

Patients that present themselves with genital complaints should give a complete history of their sex life. AB reveals that she is sexually active and has been with multiple partners in the past year. She acquired a prior sexually transmitted disease, which is chlamydia two years ago. The patient's sexual history and findings from the genital examination may necessitate further investigation. Examining patients for STDs require a thorough exam of the oral cavity, genitals, lymph nodes, and skin. If there is some anal sex, an anal exam is required. Patients with visible lesions or bumps in genital areas and are suspicious of STDs, especially syphilis, need a review of the neural system with the main focus being the motor and sensory deficits and cranial nerves. AB's sexual history of having more than one partner accompanied by ulcers on her genitals, possibly from a sexually transmitted disease requires further investigation.

After further examination, the documentation should include the following information:

• Results from the skin, genitals, lymph nodes, and oral cavity exam.
• Results from the anal exam in case of anal sex history.

Objective Information Analysis

From the objective information, body temperature, blood pressure, respiratory rate, and pulse appear to be healthy. An examination of the heart shows a regular rate and rhythm with the symmetrical chest wall. The lungs show no symptoms of fluid build-up. The genital examination shows a normal distribution of hair pattern with no swelling and masses. The urethral meatus is intact without discharge or erythema. The perineum is intact, and a healed episiotomy scar. The vaginal mucosa is pink and moist, which means it is normal. The external labia, however, shows the presence of a firm, round, small painless ulcer. Palpation of the abdomen indicates normalcy. A diagnostic HSV specimen was obtained.

Apart from the above objective information, a laboratory test is required to test for syphilis and herpes. A herpes viral culture for the ulcer is most suitable. Other tests, like the Polymerase chain reaction (PCR) test, may also be conducted (Gayet-Ageron et al., 2015). However, PCR exams are expensive and may not be available. In case the PCR and culture tests are unavailable, it is best to use a direct fluorescent antibody exam.

In the case of syphilis, direct investigation of the ulcer using darkfield microscopy test or fluorescent antibody to Treponema palladium may be reliable. If the preceding methods are not available a rapid plasma reagin test (RPR), or Venereal Disease Research Laboratory (VDRL) test may suffice (Gupta, 2018). However, the RPR and VDRL tests are not specific, and they call for another particular treponemal test, for instance, the T.pallidum agglutination Assay (TP-PA) test (Gupta, 2018). Other laboratory tests include tests for chlamydia and HIV because AB may present with a new STD suggesting concurrent exposure to HIV.

Yes. However, the presentation of a painless ulcer in the genital area may not be conclusive enough to make a correct assessment. Many challenges arise while assessing genital ulcers. Further tests are required to ensure there are a proper assessment and diagnosis of such ulcers. The tests should help to a ascertain the cause of the genital ulcer. In this case, the initial evaluation of chancre may be appropriate since it is consistent with the early stages of syphilis (Gayet-Ageron et al., 2015). The ulcer is not compatible with herpes since herpes presents with many shallow lesions with exudate (Bradshaw & Venkatesan, 2016). The ulcer is not classic for chancroid, which manifests as painful deep ulcers with rough edges and tender lymphadenopathy of the groin, which may fester (Bauer & Janowicz, 2018). Other non-STD diagnoses may be considered but knowing AB's sexual history with multiple partners, STD's should first be ruled out.

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

Yes. Diagnostics would be appropriate in this case. The patient presents with a single, painless well-rounded ulcer indicating the possibility of the chancre. A diagnostic exam is required to test the lymphatic nodes for any mild tenderness for confirmation. The use of direct fluorescent antibody testing or darkfield microscopy will help identify the Treponema pallidum. Positive results on the nontreponemal serologic testing, for example, the VDRL or RPR will help to confirm the assessment.

The fluorescent treponemal antibody absorption or the T.pallidum agglutination Assay (TP-PA) test confirms the VDRL and RPR testing (Gayet-Ageron et al., 2015). These diagnostic tests will help in detecting, affirming, and ruling out of STDs. A diagnostic test is useful in screening for particular conditions in patients with increased risk and evaluating the effects of the treatment as well as monitoring the progression of the disease. For example, in case of positive results for syphilis, treatment involves a single dose of intramuscular penicillin G benthazine. Follow-up diagnostic testing will help in evaluating the effects of penicillin on the patient.

Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

Yes. I would accept the current diagnosis. Clinical presentation forms the basis of the initial treatment of genital ulcers. The purpose of further diagnosis is required if the condition presents other symptoms. However, it is essential to perform diagnostic testing to help in detecting, confirming, and ruling out of STDs.

Possible Conditions Considered as Differential diagnosis

Genital ulcers differential diagnosis is broad. Some of the common conditions include syphilis, genital herpes, and chancroid. Primary syphilis often starts with one painless, well-rounded chancre that has a clean base and hardened border (Gayet-Ageron et al., 2015). When the patient presents with symptoms for treatment, the single chancre of initial infection may still be visible or may have developed. Chancroid is usually non-hardened, painful with serpiginous or wave-like border, with a dying, and often purulent exudate (Bauer & Janowicz, 2018). Herpes simplex is generally present with many vesicular lesions that burst to transform into shallow ulcers (Bradshaw & Venkatesan, 2016).

Other not so common STD causes of genital ulcers include lymphogranuloma venereum, acute HIV infection, and granuloma inguinale. The non-STD causes of genital ulcers include candidiasis, trauma, Behcet's syndrome, trauma, Reiter's syndrome, psoriasis, scabies, and fixed-drug eruption. Also, some infections may occur concurrently. In this particular case, AB is at high risk for an STD based on her past sexual history.

References

Bauer, M. E., & Janowicz, D. M. (2018). Chancroid. Diagnostics to Pathogenomics of Sexually Transmitted Infections, 277-291.

Bradshaw, M. J., & Venkatesan, A. (2016). Herpes simplex virus-1 encephalitis in adults: pathophysiology, diagnosis, and management. Neurotherapeutics, 13(3), 493-508.

Gayet-Ageron, A., Sednaoui, P., Lautenschlager, S., Ferry, T., Toutous-Trellu, L., Cavassini, M., ... & Schrenzel, J. (2015). Use of Treponema pallidum PCR in the testing of ulcers for diagnosis of primary syphilis. Emerging infectious diseases, 21(1), 127.

Gupta, K., Bhardwaj, A., Dash, S., & Kaur, I. R. (2018). Role of Treponema pallidum hemagglutination assay for diagnosis of syphilis in low titers of VDRL-reactive sera: A prospective study from a large tertiary care center of East Delhi. Journal of family medicine and primary care, 7(6), 1594.