The use of contraceptives is also important to know. Knowing about the patient’s menstrual
cycle history is imperative. The practitioner should note if the patient has regular or heavy periods in addition to how often. Objective Data Objective data is observable and measurable and can be obtained through vital signs, physical examination, and laboratory/diagnostic testing[ CITATION Bri17 \l 1033 ] . In addition to the objective data given in this case, there is much information missing. An oral examination needs to be completed to see if the patient has any mouth sores or ulcers since she possibly has an STD. Since the patient’s las pap smear was three years ago, a pap smear should be completed. While doing the pap smear, the practitioner should look for any other lesions or discharge. The practitioner should also document if there is any indication of foul smell or odor. The color of the ulcer and whether the borders are indurated should be documented. The patient’s skin should also be inspected to determine if there is the presence of chancre sores on the skin as lesions are also noted on the skin with syphilis. A pregnancy test should be completed to determine if the patient is pregnant. Cultures should be obtained to know the cause of the sores. I s the Assessment Supported by the Subjective and Objective Information? By definition, a chancre is a papule that red in colour that gradually begins to erode. This forms a painless, clean ulcer with a smooth, raised border [ CITATION The182 \l 1033 ]. The chancre is most commonly found on the external genitalia and develops ten to ninety days with an average of twenty-one days after infection[ CITATION Bro03 \l 1033 ]. These patients are sexually active and is transmitted through direct contact with a syphilis sore [ CITATION Bal \l 1033 ]. Since this patient states she is sexually active and has more than one sexual partner, the diagnosis is supported by the data provided.
Relevance of Diagnostics for this Case To make a definitive diagnosis of chancre, scrapings from the ulcer should be collected and microscopally examined. If the patient is positive for chancre, spirochetes will
- Summer '15
- Sexual intercourse, Human sexual behavior, Molluscum contagiosum