Genitalia Assessment Health, Medicine, Nursing Case Study

Genitalia Assessment
Your Name
Subject and Section
Professor’s Name
Date of Submission
Date of assessment: August 9, 2020
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 five small, painless, and rough bumps along her labia majora and six on her vagina which she noticed a week ago. She is sexually active and does not use condoms or vaginal diaphragms. Before they had sex, they usually inject drugs and share the needle. She had multiple partners in the past year and some of them had multiple partners also. She began engaging in sex when she was 18 y/o. There is no vaginal discharge.
PMH: The patient has asthma since childhood but it occurs only when she runs fast or in extreme weather conditions. She was diagnosed with chlamydia 2 years ago and she completed the treatment for it. 3 years ago, she had undergone a Pap smear and the result was normal without dysplasia. She did not have any recent surgeries or hospitalizations.
Immunizations: HBsAg and Tetanus toxoid in December 2018.
Medications: Symbicort 160/4.5mcg twice daily for maintenance. Combination pill (oral contraceptives) every day for maintenance. She does not take herbal or any OTC drugs.
Allergies: NKDA
FH: No hx of breast or cervical cancer. Father has a hx of HTN. Mother has a hx of HTN, GERD
Social: Denies tobacco use; occasional etoh; (+) illicit drug use. She is married with 3 children (1 girl and 2 boys) and lives in an apartment in a village. She is a working student and goes to school every MWF from 10 AM to 3 PM. She works full-time every TTh from 8 AM to 3 PM as a barista in Starbucks and part-time during MWF from 4 PM to 8 PM. During weekends, she spends time with her family by going to the park. Her husband is also a working student which makes them financially-challenged.
OB-GYN: Menstrual hx: Menarche at 11 y/o. LMP: August 5, 2020, heavy flow, 5 pads per day, the duration is 4 days. She does not experience PMS and contact or intermenstrual bleeding. Gynecologic hx: G3P3-3-0-0-3 all are NSVD. She uses oral contraceptives (combination pill) and does not miss a dose. She does not feel pain during sex. Does SBE every month and there are no lumps. No hx of gynecologic surgeries, infertility. She had vaginal discharges 2 years ago.
Psychosexual hx: The patient cannot hold on having sex regularly prompting her to cheat on her husband. Her libido is always high and likes to have an orgasm at least twice a week.
Review of Systems
GENERAL: No fever, chills, weight loss, weakness, or fatigue
HEENT: No visual loss, double or blurred vision. No hearing loss, sore throat, sneezing, problems of congestion. The patient sometimes experiences difficulty in breathing due to asthma. No lymphadenopathies on the cervical area.
SKIN: No itching or rashes on the extremities, trunk, and face.
CARDIOVASCULAR: No chest pain, pressure, or discomfort. Does not experience palpitations or high blood pressure.
RESPIRATORY: No SOB or cough.
GIT: No vomiting, nausea, bloody discharges, or abdominal pain. (+) hx of hepatitis B last July 2016.
NEUROLOGIC: No headache, syncope, dizziness, ataxia, tingling, or ex...