1. Subjective
Patient’s chief complaint, reason for visit
Ms. Richards arrived complaining that she was experiencing severe anal pain, so much so that using a tissue was also proving impossible. She claimed the pain began a couple of days earlier and has aggravated considerably since.
History of Present Illness
Ms. Richards arrived complaining of anal pain which commenced a couple of days earlier and has aggravated since. With regard to her intimate relationships, Ms. Richards states that though she has a boyfriend, their relationship isn’t serious as the two are also seeing other people. According to internal assessment reports, patient has normal hair distribution, an intact perineum, and intact urethral meatus without any discharge or inflammation. However, patient experiences unbearable pain on vaginal opening palpation, redness, and edema. Further, a mass has been identified on the right, with spontaneous, dark-yellow, smelly secretion with palpation over the Bartholin's glands.
Physical examination reports reveal normal vital signs, cardiovascular, respiration and acute abdomen limits. A non-tender, soft mass, mobile relative to underlying muscle and bone, was palpated. Soft tissue was found to be swollen and highly prominent at the posterior. No tenderness was observed to thigh palpation, nor was any evidence discovered of warmth or erythema across the region. Passive and active range of knees’ and hips’ bilateral motion was painless and full. Lower bilateral extremities had typical tone and strength. A neurologic examination of patient’s lower extremity depicted normal results. Musculoskeletal examination results and gait were also found to be normal (King, Friedman, Iwenofu, & Ogilvie, 2008).
Precipitating/alleviating factors
Patient claims to enjoy an open romantic relationship and active sex life. She often consumes birth control medication and has even taken painkillers for alleviating her anal pain.
Past Medical History
Patient reports never having met with an accident, nor has she suffered any serious ailment, admission to a hospital, or surgery. Patient is somewhat overweight, with a small quantity of thigh fat. She states that in spite of exercising and eating healthy, her thighs have remained the same.
Family History
Patient’s dad was diabetic while her grandma was found to be suffering from cancer somewhere in her fifties.
Social History
Patient enjoys a healthy relationship with family members. She is employed as a primary school teacher, which is why she can easily afford her apartment’s rent. She enjoys an open romantic relationship and active sex life.
Review of Systems
System review proved non-contributory, with physical examination results being typical. Peripheral blood count, urinalysis and serum chemistry at the time of hospitalization were normal.
2. Objective
Diagnostic Study
Bartholin's gland infection
Situated in a symmetrical arrangement at the vaginal opening’s posterior are a couple of pea-sized “Bartholin’s glands”, which have a key role to play in women’s reproductive system. Their function is secreting...
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