Focused SOAP Note on Genitalia Assessment

Focused SOAP Note on Genitalia Assessment

Focused SOAP Note on Genitalia Assessment
Episodic/Focused GENITALIA ASSESSMENT note 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 external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner during the past year. Her initial sexual contact occurred at age 18. She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed. PMH: Asthma Medications: Symbicort 160/4.5mcg Allergies: NKDA FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys) Objective: VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs Heart: RRR, no murmurs Lungs: CTA, chest wall symmetrical Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia. Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, neg McBurney Diagnostics: HSV specimen obtained Assessment: Chancre QUESTIONS: Focused SOAP Note on Genitalia Assessment . Using current evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature. A) Analyze the subjective portion of the Episodic/Focused Genitalia Assessment note. List additional information that should be included in the documentation. B) Analyze the objective portion of the note. List additional information that should be included in the documentation. C)Is the assessment supported by the subjective and objective information? Why or why not? D) Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis? E)Would you reject/accept the current diagnosis? Why or why not? F)Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.Focused SOAP Note on Genitalia Assessment
Analysis of a Focused SOAP Note on Genitalia Assessment for a 21 Year-Old Caucasian Female College Student
Patient AB is a 21 year-old Caucasian female presenting with a chief complaint of “bumps” on the bottom. On history taking, the patient states that the bumps feel rough to the touch and are painless. She denies any vaginal discharge but accepts a history of sexually transmitted infection (STI) in the form of Chlamydia. She is a married woman and a mother of three children – a girl and two boys. According to Shannon and Klausner (2018), sexually transmitted infections are an epidemic among adolescents and young adults such as this 21 year-old mother of three. In the US, STIs are a common cause of morbidity with genital sores being a major presentation among patients presenting with a diagnosis of STI. Among teenagers and young adults, the carefree attitude that is evident from the fact of having multiple sexual partners places them at a higher risk for contracting STIs. Even though this woman is married, the possibility of having multiple sexual partners cannot be ruled out. In this paper, an analysis is made of the 21 year-old’s genitalia assessment presented in an episodic SOAP note format. The subjective, objective, and assessment options are individually assessed and any missing information addressed in this paper. Focused SOAP Note on Genitalia Assessment
The Subjective Portion of the Episodic SOAP Note for Patient AB
Analysis of this portion of the SOAP note shows that the chief complaint (CC), the history of presenting illness (HPI), the past medical and surgical history, allergies, current medications, family and social history have been presented. The obvious omission is therefore the review of systems (ROS) to complete the subjective assessment in SOAP format. The missing ROS should have been as follows:
Review of Systems or ROS
General: Patient AB denies any weakness, fever, fatigue, or malaise.
HEENT: She denies having blurred vision, double vision, or light intolerance. She denies having an ear discharge, tinnitus, or hearing loss. She is not sneezing and has no nasal discharge. Her throat is not sore.
Integumentary: She denies itchy skin, rashes, or eczema. She also denies suffering from allergic dermatitis.
Gastrointestinal: She denies irregular bowel movements. Her last bowel motion was in the morning after waking up. She also denies having diarrhea, nausea, vomiting, or constipation.
Cardiovascular: She denies any chest pain, feeling faint, or palpitations. She has not experienced any palor in her extremities.
Respiratory: She denies having any cough, overt edema of lower limbs, or difficulty in breathing.Focused SOAP Note on Genitalia Assessment
Genitourinary: Reports having a painless but rough lesion on the external genitalia. She denies any pain or cloudiness of urine on micturition. She has no frequency of micturition and also denies pregnancy. The last menstrual period was a week before the current visit.
Neurological: She denies having fainting attacks. Also denies having problems with bowel and bladder control. There is no gait disturbance or pins and needles in the extremities.
Musculoskeletal: She denies muscle or joint pains as well as back pain. She has no joint stiffness or a limit in the range of motion around her joints.
Endocrinologic: She denies taking excessive volumes of water or passing large amounts of urine. She also denies excessive diaphoresis and heat intolerance.
Lymphatics: She denies having palpable lymph nodes or undergoing splenectomy in the past.
Hematologic: She denies feeling dizzy, faint, or experiencing unprovoked bruising.
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Psychiatric: Patient AB also denies a history of anxiety, depression, ideas of self-harm, or hallucinations.
Allergic/ Immunologic: She has not had any food, medication, or environmental allergies in the past. She also denies rhinitis, asthma, or hives.
The Objective Portion of the Episodic SOAP Note for Patient AB and Appropriateness of Diagnostics
The objective assessment of patient AB was well and thoroughly done with vital signs taken and a proper physical examination of the genitalia performed. This was positive for firm, round, but painless lesions present on the external genitalia. However, the only additional information that should be included in this documentation is further diagnostic tests. This is in view of the fact that there are a myriad of other possible differential diagnoses of conditions that also present as a genital lesion. These include syphilis, molluscum contagiosum, genital herpes, and granuloma inguinale amongst others (Hammer & McPhee, 2018). The only test ordered and noted in this documentation is that for the herpes simplex virus or HSV that causes herpes genitalis. Therefore, the additional information that should be included in this presented SOAP documentation is about additional diagnostic tests to look for the other differential diagnoses. These are:Focused SOAP Note on Genitalia Assessment

A swab of the lesion for microscopy

The examination of a swab taken from one of the painless lesions on the external genitalia will help in establishing whether there are Donovan bodies, in which case it would be granuloma inguinale (Copeland & Decker, 2016). Alternatively, the visualization of a hyperplastic squamous epithelium would suggest that the diagnosis is that of molluscum contagiosum (Singla et al., 2018).

A VDRL test

The venereal disease research laboratory or VDRL test is for syphilis and is a quite reliable test. This must be done to rule out this STI as it also presents as a painless ulcer on the genitalia (Hammer & McPhee, 2018).Focused SOAP Note on Genitalia Assessment

A urinalysis

Last but not least is a urinalysis. This is a routine test for any patient presenting with an STI and may give valuable information (such as the pH and physical appearance of cloudiness) that may help make the correct diagnosis (Hammer & McPhee, 2018).
Is the Assessment Supported by the above Subjective and Objective Information? Would the Current Diagnosis be Accepted or Rejected?
The assessment or diagnosis of a (syphilitic) chancre does not appear to be supported by the subjective and objective information as seen above. A chancre is traditionally not raised as bump as patient AB reports in the subjective assessment. It is indeed usually painless but generally not elevated. On the contrary, the subjective and objective information seems to support the diagnosis of molluscum contagiosum (Singla et al., 2018; Hammer & McPhee, 2018). Based on this alone, the current diagnosis of a chancre is rejected in favor of molluscum contagiosum caused by the poxvirus or molluscum contagiosum virus (MCV).Focused SOAP Note on Genitalia Assessment
Possible Differential Diagnoses
From the foregoing, the three possible differential diagnoses in this case are:

Syphilis: This is the second most probable diagnosis because a syphilitic chancre is also painless. However, it is not usually elevated as a “bump” (Hammer & McPhee, 2018).
Granuloma inguinale: This is another STI that also presents with a painless ulcer as in this case. However, the ulcer in granuloma inguinale bleeds very easily when touched yet this was not a finding in the objective assessment (Hammer & McPhee, 2018; Copeland & Decker, 2016).
Genital herpes: This is caused by the herpes simplex virus and is the least probable because its genital lesion is usually quite painful (Sauerbrei, 2016). The findings in the objective portion of the SOAP note were those of a painless genital lesion.Focused SOAP Note on Genitalia Assessment

References
Copeland, N.K., & Decker, C.F. (2016). Other sexually transmitted diseases chancroid and donovanosis. Disease-a-Month, 1-8.  https://doi.org/10.1016/j.disamonth.2016.03.016
Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. McGraw-Hill Education.
Sauerbrei, A. (2016). Herpes genitalis: Diagnosis, treatment and prevention. Geburtshilfe Frauenheilkd, 76(12), 1310–1317. https://doi.org/10.1055/s-0042-116494
Shannon, C.L. & Klausner, J.D. (2018). The growing epidemic of sexually transmitted infections in adolescents: A neglected population. Current Opinion in Pediatrics, 30(1), 137-143. http://dx.doi.org/10.1097/MOP.0000000000000578
Singla, C., Mahajan, B.B., Kaur, T., Malhotra, S.K., & Sharma, N. (2018). Genital molluscum contagiosum in females – therapeutic efficacy and comparative evaluation of topical 10% and 20% potassium hydroxide. Indian Journal of Sexually Transmitted Diseases and AIDS, 39(2), 102-106. https://doi.org/10.4103/ijstd.IJSTD_100_16
Focused SOAP Note on Genitalia Assessment