Genitalia Assessment SOAP note case study – Special Examinations—Breast, Genital, Prostate, and Rectal

In this assignment, you will analyze a SOAP note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

GENITALIA ASSESSMENT

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 over 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 Genitalia Assessment SOAP note case study – Special Examinations—Breast, Genital, Prostate, and Rectal
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 with a healed episiotomy scar present. 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 Genitalia Assessment SOAP note case study – Special Examinations—Breast, Genital, Prostate, and Rectal
Assessment:

To prepare:

With regard to the SOAP note case study provided:

consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
To complete:
Analyze the SOAP note case study. Using evidence based resources, answer the following questions and support your answers using current evidence from the literature.

Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or Why not?
Would diagnostics be appropriate for this case and how would the results be used to make a diagnosis?
Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least 3 different references from current evidence based literature. Genitalia Assessment SOAP note case study – Special Examinations—Breast, Genital, Prostate, and Rectal

Additional Information to Include in Subjective Data

Onset-The client reported that she noticed bumps I week ago which means that she was not certain for how long they have been present. I will request the patient to explain the bumps more in terms of its size, pattern, shape, and color. In the past, have you noticed bumps or this is the first time? If you noticed them previously, did you make any efforts to treat them? Recently, have you had any fevers or illnesses? Have you undergone any recent procedures or surgeries that need anesthesia or happened to start a new medication? At the time that you discovered the bumps what were you doing? When you had chlamydia 2 years ago, did you experience similar symptoms? Recently in your house, has anyone had scabies or lice?

Location-patient initially reported external bumps on her genitalia.

Apart from the genitalia, have you noticed bumps elsewhere on your body? If there are any that are internal, can you tell?

Associated Symptoms– the patient reported that the bumps feel rough and are painless

Currently, before noticing the bumps, did you experience any form of burning or itching? Do the bumps tend to crust over, weep or ulcerate? In the entire period since you noticed them, do the bumps have the same appearance or it happened to change? Do the bumps spread?

Duration- the patient noticed the bumps one week ago but remained uncertain on their exact onset. Can you tell whether the bumps are always present throughout or if they come and go?

Aggravating factors- Are you informed of potential factors that tend to aggravate the occurrence of the bumps? Are they irritated by warm water, clothing and tight undergarments? Personally, do you often use douches and fragrant soaps? Recently, have you changed body soaps and detergents that you use?

Relieving factors- Are you aware of anything that tends to reduce/decrease their number, makes them disappear, change its texture or shape?

Alternative treatments- before seeking medical help, have you tried any topical medications or home remedies? If so, was there any appreciable change or improvement?

Scaling pain- the patient clearly reported that the bumps were painless

Can you please rate the degree to which the bumps bother and affect your life with 10 as the maximum effect?

Past Medical History: Chlamydia and Asthma

Do you have any past medical history of other STIs or Genital Herpes apart from chlamydia?

Underlying skin conditions such as psoriasis and eczema?

Have you either suffered from chicken pox or had its immunization?

Have you previously been admitted to the hospital? If so, how many times and what were the indications?

At what age were you diagnosed with Asthma and are you currently having any complications with it?

What medications were you prescribed previously for chlamydia and who prescribed them?

Past Surgical History

Have you had any major surgical operations or C-section?

Medications: the patient uses Symbicort 160/4.5mcg

Are you taking any birth control meds, medications for acne or other drugs? If yes, when did you start and do you have any issues with it so far?

Since you are asthmatic, do you have a rescue inhaler?

OTC Medications, Supplements, and Herbs

Are you currently taking any work-out supplements, vitamins or OTC medications? If so which ones?

Denies History of?

Do you have a history of Psoriasis, Syphilis, Diabetes, thyroid disease, and a recent candida or step infection and HIV?

Allergies

Do you have any food, drug, and environmental allergies?

Personal Socio-Economic History- The client is a college student, married with children (2 boys and 1 girl). The patient denied the use of tobacco, occasional ETOH.

Do you live in a single home with the children and your spouse? If she lives in a dorm, it is worth knowing how many people they share the bathrooms with. Do you use/abuse any prescription drugs and illicit drugs? What kind of work do you do? What is your husband’s occupation? What are your hobbies? Have you had any recent increase in stressors? What is the client’s cultural history, religion and support system? Genitalia Assessment SOAP note case study – Special Examinations—Breast, Genital, Prostate, and Rectal

Sexual Reproductive History- she is single and sexually active since 18 years of age. She also reports that she had more than 1 partner in the past year. She did a pap smear 3 years ago, which appeared to be normal with no dysplasia. She was diagnosed with Chlamydia 2 years ago and took a complete drug regimen.

It will be necessary to confirm if the client has had any problems since she completed treatment for chlamydia. It will also be necessary to confirm the number of sexual partners that she has had so far and discuss the use of protection. Information on her sexual orientation and how well she prescribes her gender will also be important. Have you ever gotten pregnant? Have you ever had any abortions and miscarriages? Do you know the sexual status of your partners? Do you engage in anal sex? Genitalia Assessment SOAP note case study – Special Examinations—Breast, Genital, Prostate, and Rectal. Do you undertake self-breast exams, if yes, how frequently?

Family History: No previous history of cervical cancer or cervical cancer. Father has a history of Hypertension and mother has a history of GERD and Hypertension.

It will be important to know the age of the client’s parents and if they are deceased or alive. Additional history on both paternal and maternal grandparents and siblings should also be obtained.

Review of Systems

General: Have you had any recent weight gain or loss, symptoms of fever and fatigue?

HEENT: Have you had a recent sore throat, noticed any sores in your oral cavity and throat or white coating on your tongue?

Breasts: Do your breasts have any drainage, lumps, tenderness or lumps? Genitalia Assessment SOAP note case study – Special Examinations—Breast, Genital, Prostate, and Rectal.

Respiratory: Any chest tightness, cough, wheezing or pleurisy?

Cardiovascular/ Peripheral Vascular: Any palpitations, chest pain, edema, murmur and arrhythmias?

Gastrointestinal: Have you experienced symptoms of vomiting, nausea, heartburn, vomiting. Do you experience fresh blood in stool, gray or black stools?

Genitourinary: What is your last LMP? Do you have any issues with your menstrual cycle? Do you experience urinary symptoms of hesitancy, pain, burning and increased frequency? Do you have any tenderness on the vulval region, dyspareunia, foul odor or vaginal bleeding?

Skin: Do you have any histories of eczema, skin cancer, and psoriasis or removal of lesions? Have you experienced any recent or past increased sensitivity to lotions, soaps, and detergents?

Additional Information to Include in Objective Data

Physical Exam:

Vital signs: Temp 98.6, PR 92, RR 16, BP 120/86, Ht 5’10”, Wt. 169 lbs., BMI = 24.2.

General: I will describe the patient’s stature, walking gait, grooming, eye contact and affect

HEENT: I will assess for edema, any drainage, cold sores, tonsils, lesions, oral thrush and look for systemic signs of infection of HSV or other viral infections. Genitalia Assessment SOAP note case study – Special Examinations—Breast, Genital, Prostate, and Rectal.

Neck: I will assess for nodal tenderness, enlarged nodes at the cervical and clavicular regions, jugular venous distension and bruits.

Chest: I will assess for labored or non-labored breathing, No breast lumps, nipple discharge, tenderness or nodules. No enlargement of the axillary nodes.

Lungs: Symmetrical chest wall, CTA. Check for nasal flaring, retractions and wheezing.

Heart & Peripheral Vascular-Rapid Respiratory rate, no murmur, no edema.

Abdomen: Soft, non-tender, normal and active bowel sounds, no rebound tenderness, negative murphy’s and McBurney’s sign

Genital/Rectal: Normal distribution of hair, normal hair pattern, no swellings or masses, the urethral meatus has no discharge or erythema and is intact; the perineum is also intact with a healed scar for an episiotomy. The vaginal mucosa is moist, has rugae and is pink in color. The POS is firm, small and round. On the external labia, a painless ulcer is noted.

It is notable that the client has not had a pap smear for 3 years and had a history of chlamydia. Therefore, I will immediately do a pap smear and inspect the cervix for its presentation and motion tenderness in the process. I will check for possible vaginal bleeding, and note any foul discharge or odor. I will palpate to check for enlargement and tenderness of the inguinal lymph nodes. I will check for discharge in the scene and Bartholin glands. I will also note if the ulcer is indurated, whether or not it is the only one and its color. Genitalia Assessment SOAP note case study – Special Examinations—Breast, Genital, Prostate, and Rectal.

Skin: I will examine the skin for dryness, warmth, and pinkness. I will also check other regions for redness, discoloration, scaling, and patches.

Diagnostics

An HSV specimen was obtained for viral culture. To obtain results that are more specific, it will take 1-7 days.

A PH litmus and wet mount KOH should also be considered depending on the PE. Aspects such as clue cells, high PH and a gray discharge should be looked for.

Nontreponemal, PCR, EIA and VDRL tests should be considered for syphilis serology (Gayet-Ageron, et al., 2015).

A small scraping should also be obtained to look for spirochetes

A tzanck smear from the vesicles base should also be done. This test is definite for HSV. The findings that are most likely to be present are multinucleated giant cells but is only if the specimen will be from a herpes lesion that is intact. Genitalia Assessment SOAP note case study – Special Examinations—Breast, Genital, Prostate, and Rectal.

Assessment: Possible Differential Diagnosis

Acute Contact Dermatitis
Syphilis
Herpes Progenitalis(Simplex II)

Syphilis– This most likely but confirmation with serology is needed. Since the patient has previous STIs history with multiple sexual partners, she is at risk of syphilis. Besides, the place where the lesion is located on the external labia permits easy contact with a direct syphilitic sore (Gayet-Ageron, et al., 2015). Based on the fact that currently, the ulcer is painless, with no itching, burning or pain prior to its eruption, syphilis is a likely diagnosis but previous diagnoses should be ruled out.

Both the objective and subjective data supports a Syphilis diagnosis. However, intensive diagnostics and questioning of the patient should be considered to obtain information that is more precise. For instance, it is important to know about the lesion’s borders, if its base is clear and firmness.

Acute Contact Dermatitis– this is not likely since the patient has no history of allergens. It should also be noted that the client’s history of her work environment and most recent activities could lead to this diagnosis. If it were contact related, large erythema region could also be expected (Seller& Symons, 2012) Genitalia Assessment SOAP note case study – Special Examinations—Breast, Genital, Prostate, and Rectal.

Herpes Progenitalis (Simplex II) – The assumption that only a single ulcer exists minimizes the possibility of Herpes Progenitalis, besides, the ulcer that was described was firm. In case of a previous infection, it is usually intensive while the recurrent tend to be localized with patches. Lesions can even burn and are always painful (Wagenlehner, et al., 2016).

References

Dains, J. E., Baumann, L. C., & Scheibel, P., (2016). Advanced health assessment and clinical diagnosis in primary care (5^th ed.). St. Louis, MO: Elsevier Mosby.

Gayet-Ageron, A., Sednaoui, P., Lautenschlager, S., Ferry, T., Toutous-Trellu, L., Cavassini, M., & Schrenzel, J. (2015). Use of Treponema pallidum PCR in the testing of ulcers for diagnosis of primary syphilis. Emerging infectious diseases, 21(1), 127.

Seller, R. H., Symons, A.B. (2012). Differential Diagnosis of Common Complaints (6^th ed). Philadelphia, PA.: Elsevier-Saunders Genitalia Assessment SOAP note case study – Special Examinations—Breast, Genital, Prostate, and Rectal.

Seidel, H.M., Ball, J. S., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidels’s guide to physical examination (8^th ed.). St. Louis, MO: Elsevier Mosby

Wagenlehner, F. M., Brockmeyer, N. H., Discher, T., Friese, K., & Wichelhaus, T. A. (2016). The presentation, diagnosis, and treatment of sexually transmitted infections. Deutsches Ärzteblatt International, 113(1-2), 11 Genitalia Assessment SOAP note case study – Special Examinations—Breast, Genital, Prostate, and Rectal.