Diagnosis and Assessment in a Clinical SettingGiven the information provided in the subjective portion of the note, the clinician would want to find out if the patient has ever engaged in anal intercourse. If the patient has engaged in such intercourse, the clinician would want to know how many partners she’s had in this regard and when was the last incidence of anal intercourse. The clinician would also want to find out if the patient used protection when engaging this form of intercourse. Getting the total number of partners that this woman has had over the past year might shed some light on the situation as well. Additionally, it might be worth asking if the patient has made an obvious changes in personal hygiene or underwear. For example, the sudden usage of baby wipes in the vaginal or anal area has been found to cause irritation in some cases. Likewise, wearing underwear or thongs made out of material that can cause irritation, such as latex or polyester, which prevents proper ventilation to the skin can also cause irritation. Hence, asking the patient if she’s made an sudden changes in dress, or personal hygiene are necessary. Furthermore, asking about the last bowel movement the patient had would be valuable information, as well as asking about the nature of her bowel movements. Does the patient strain or have difficult or leaky bowel movements? Does...
The bumps should be swabbed along with a swab taken of the anus area, and a microscopic examination should be conducted (nih.gov). For example, herpes sores often break and ooze a fluid. If this is in fact a herpes outbreak, the bumps might not be at the stage where they yet break and emit a fluid. Conducting a swab might also help one determine if these bumps are the telltale sores or fever blisters that are often red, white or clear, that forms on the genitalia. Testing the area to determine if it looks swollen would also help in determining a diagnosis. Assessing if the sores are appearing in clusters or groups is also important to note down for the patient’s file; alternatively, the sores or bumps might be manifesting in a more individualized manner. A clinician who has experience in diagnosing herpes should be able to tell if these are the bumps commonly associated with herpes; even if they are not yet emitting a fluid, an experienced clinician can generally tell if that will eventually happen. “The sores will burst and the fluid will begin to discharge, leading to the formation of wet ulcers. Just like cold sores,…
