Analyzing the history of previous diseases, as well as the current health condition is crucial for positive treatment outcomes. The assessment of the subjective and objective data regarding a client’s health is paramount for the correct diagnosis made. Thus, the purpose of the paper is to evaluate the fullness of the documentation given, assess the patient’s condition, and elaborate on the diagnosis concerning the case study provided.
The additional information that should be added to the documentation includes the last time the patient participated in sexual activity, whether or not she used protection when having sex and the nature of her partner’s symptoms. Establishing the existence of pain during intercourse and the presence of similar swellings in the past, as well as any weight loss or myalgia, is critical. Additionally, the patient’s history of HIV, syphilis or hepatitis testing facilitates the determination of the most likely diagnosis.
The information that should be added in the objective section includes the dimensions of the ulcer in millimeters, the presence or absence of inguinal adenopathy, and whether the regional lymphadenopathy is bilateral or unilateral. It is also essential to determine whether the inguinal adenitis is firm, mobile, painless, or discrete. It is necessary to highlight the presence of any associated skin changes, the consistency of the edge and base of the ulcer, and the lesion’s texture. Finally, the nature and color of the tissue surrounding the ulcer and the presence or absence of any induration, redness, or suprainfection must be noted.
The assessment is supported by the information presented in the case study. The subjective data provided includes the assertion that the swellings in the genital area are painless and rough. Chancres in primary syphilis are often described as painless papules that gradually become eroded and indurated (O’Byrne & Macpherson, 2019). There is a history of sexual activity with multiple partners, which increases the chances of infection. Syphilis is transmitted in the first 1-2 years after exposure (Peeling et al., 2018). The objective data demonstrates that the patient is afebrile and has a small, round and painless ulcer on her external labia. This is consistent with chancres in primary syphilis, which are round with a cartilaginous consistency on the edges and the base (O’Byrne & Macpherson, 2019). In addition, the lesions are often associated with inguinal lymphadenopathy.
To evaluate the condition of a patient with a chancre, diagnostics are vital. Treponemal tests such as the Treponema pallidum particle agglutination assay and the IgG/IgM enzyme immunoassay are useful in determining whether the patient is infected (Goza et al., 2017). In addition, anti-cardiolipin tests such as the rapid plasma reagin or venereal disease research laboratory test (VDRL) are used in the diagnosis of primary syphilis (Goza et al., 2017). However, the latter is rarely used to test an individual who has a chance. It is vital to note that treponemal analyses often turn positive in the first two weeks of infection. Non-treponemal tests are often used to assess response to treatment and evaluate the stage of infection. Higher titers are associated with an early infection while lower antibody levels are linked to the disease’s latent phase.
Concerning the case study, the current diagnosis is acceptable because the patient has the key symptoms which are associated with it. For instance, the patient is afebrile, presents with a painless ulcer, and has a history of sexual contact with multiple partners in the past year. Additionally, the differential diagnoses for this case study may include the following: genital herpes, chancroid, and lymphogranuloma vender um.
First, herpes is more common than syphilis in the American population. Herpetic ulcers often present as multiple painful superficial swellings in the anogenital region (Liu et al., 2017). In addition, the lesions are blister-like and only ulcerate after disease progression. It is vital to note that, unlike syphilitic ulcers, these lesions test positive for herpes after scrapings from the base which are cultured. Herpes is a differential diagnosis because its clinical features are remarkably similar to chancre. For instance, lesions are located in the anogenital region, infected patients develop ulcers, and the disease is sexually transmitted.
Second, chancroid lesions have specific features that distinguish them from those associated with primary syphilis. These swellings are often numerous, painful, and lack induration (Liu et al., 2017). The genital papules evolve into pustules, which rupture to develop into superficial ulcers with uneven and undermined edges (Lautenschlager et al., 2017). Additionally, the ulcers’ bases are granulomatous and filled with purulent exudates. If left untreated, the lesions persist for months, unlike chancre, which resolves after a few weeks (Lautenschlager et al., 2017). In addition, many of the patients may present with kissing ulcers caused by autoinoculation from primary lesions. It is vital to note that some infected individuals develop buboes that may rupture spontaneously (Lautenschlager et al., 2017). There are some similarities between chancroid and the current diagnosis that make it a differential diagnosis. For instance, the lesions form in the anogenital area, both are sexually transmitted, and the ulcers in both cases are superficial.
Finally, it is considered that lymphogranuloma vender um lesions are painless and self-limiting and are often located in the genital mucosa or rectum. However, Weiss and Sano (2018) note that the patients may have painful inguinal lymphadenopathy, fever, chills, and malaise. This is significantly different from patients diagnosed with chancre because fever, malaise, and painful genital lesions are often absent. However, the disease qualifies as a differential diagnosis because the lesions are self-limiting and painless. In addition, the illness is transmitted when individuals have sexual intercourse without protection.
References
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Lautenschlager, S., Kemp, M., Christensen, J. J., Mayans, M. V., & Moi, H. (2017). 2017 European guideline for the management of chancroid. International Journal of STD and AIDS, 28(4), 324–329. Web.
Liu, X. K., Wang, Z. S., & Li, J. (2017). Kissing chancre of primary syphilis.IDCases, 7(1), 38– 39. Web.
O’Byrne, P., & Macpherson, P. (2019). Syphilis.British Medical Journal, 365(14159). Web.
Peeling, R. W., Mabey, D., Kamb, M. L., Chen, X., David, J., Benzaken, A. S., Street, K., Hepatitis, V., Union, P., & Hepatitis, V. (2018). Syphilis.Nature Reviews Disease Primers, 3(17073), 49. Web.
Weiss, E., & Sano, M. (2018). Proctocolitis caused by lymphogranuloma venereum.Canadian Medical Association Journal, 190(11), E331–E333. Web.