Episodic/Focused SOAP Note Template – Assessing the Genitalia and Rectum

Episodic/Focused SOAP Note Template – Assessing the Genitalia and Rectum

Assessing the Genitalia and Rectum

Episodic/Focused SOAP Note Template

Patient Information:

JW       Age: 21         Sex: Female                 Race: Caucasian

S.

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CC(chief complaint) “I have bumps on my bottom that I want to have checked out. ”

HPI:  This 21-year-old Caucasian female presents to our clinic complaining of painless, rough bumps on her genital region.  The onset of these bumps was approximately one week ago.  JW reports being sexually active with more than one partner over the past year.  She also has a history of chlamydia 2 years ago with completed treatments.  She reports being sexually active since the age of 18 years of age.

Current Medications:  Symbicort 160/4.5mcg PO twice daily

Allergies: NKDA

PMHx: Chlamydia, Asthma

Soc Hx: Denies tobacco use; occasional ETOH, married, 3 children (1 girl, 2 boys)

Fam Hx:  No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD

ROS:

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat. Episodic/Focused SOAP Note Template – Assessing the Genitalia and Rectum

SKIN:  Reports bumps on around genital region, no vaginal discharge reported.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. Denies palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Denies urinary symptoms. LMP: 03/22/18. Last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. Denies change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  history of asthma;  denies hives, eczema or rhinitis.

O.

VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs

General:  Awake, alert, and oriented x4 female.  She is well groomed and well-nourished.  Denies fever, chills, fatigue, nausea, and vomiting.

Cardiovascular:  +S1, S2, heart rate and rhythm regular, no murmur, no peripheral edema observed.

Respiratory: CTA, chest wall symmetrical

Gastrointestinal: Abdomensoft, normoactive bowel sounds, neg rebound, neg murphy’s, neg McBurney

Genitourinary: 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

Diagnostic results:  HSV results pending

A.

Differential Diagnoses 

1) Human Papilloma Virus (HPV)  HPV infection commonly causes warts. Some  HPV infections may cause cervical cancers. There are more than 100 varieties of HPV (Hammer & McPhee, 2014).  Most HPV infections will not lead to cancer. However, some types of genital HPV may cause cervical cancer (Hammer & McPhee, 2014).  HPV may be responsible for cancers of the anus, penis, vagina, vulva, and oropharyngeal. Episodic/Focused SOAP Note Template – Assessing the Genitalia and Rectum

Signs and Symptoms

The body’s immune system combats  HPV before creating warts.  When warts appear, they vary in appearance depending on the type of HPV involved: genital warts, common warts, plantar warts, and flat warts (Hammer & McPhee, 2014).  Genital warts in women appear mostly on the vulva but may also appear near the anus, cervix, and vagina.

Risk Factors

An increased amount of sexual partners makes it more likely to contract HPV.  Genital warts are most common in adolescents and young adults (Hammer & McPhee, 2014).  Patients with a weakened immune system are at greater risk of HPV.  Exposed areas of skin that have been punctured or opened are at risk of developing common warts (Hammer & McPhee, 2014).

Diagnostic Tests

The following tests may be recommended if the genital warts are not visible.

• Acetic acid solution test consists of a vinegar solution applied to HPV-infected genital areas and turns these areas white (Hammer & McPhee, 2014).
• Pap Smear consists of a clinician collecting a sample of cells from the cervix or vagina to send for laboratory analysis. A Pap test may be able to reveal abnormal cells that may lead to cancer (Hammer & McPhee, 2014).
• DNA test consists of analyzing cells from a patient’s cervix and is able to recognize DNA that is considered high-risk of HPV and linked to genital cancers (Hammer & McPhee, 2014).

2) Genital Herpes:  A  sexually transmitted infection (STI) caused by the herpes simplex virus (HSV) (Goljan, 2014).  The virus is primarily transmitted sexually.  The virus typically lies dormant and may emerge several times a year (Goljan, 2014).

Signs and Symptoms

Symptoms may begin between two to 12 days after exposure to HSV.  Symptoms if present may include:

• Pain or itching in the genital region
• Red bumps or white blisters
• Ulcers that may ooze or bleed
• Scabs (Goljan, 2014).

During the initial outbreak,  flu-like symptoms may present such as swollen lymph nodes in the groin, headache, muscle aches, and fever (Goljan, 2014). Episodic/Focused SOAP Note Template – Assessing the Genitalia and Rectum

Risk Factors

The risk of becoming infected with genital herpes may increase the patient:

• Is Female.  The mode of transportation is much easier from men to women than it is women to men.
• Multiple sexual partners (Goljan, 2014).

Diagnostic Tests

A clinician may diagnose genital herpes by the physical examination along with the results of some of the following lab results:

• Viral culture of the sore
• Polymerase chain reaction (PCR) test
• HSV antibody test. This test may detect past infection of HSV (Goljan, 2014).

3) Bartholin’s cyst:  The Bartholin’s glands are located on each side of the vaginal opening and secreted fluid that helps lubricate the vagina (McCance , Huether, Brashers, & Rote, 2014).  When the openings of the Bartholin’s glands become obstructed, fluid will back up into the gland.  This will result in a painless swelling called the Bartholin’s cyst (McCance et al., 2014).  The fluid within the cyst may become infected and collect pus which will develop into an abscess (McCance et al., 2014).

Signs and Symptoms

The cyst may present as a lump or mass near the vaginal opening.  The cyst may usually be painless, it can be tender.  When a cyst is infected the following symptoms may be present:

• A tender, painful lump near the vaginal opening
• Discomfort while walking or sitting
• Pain during intercourse
• Fever (McCance et al., 2014).

Diagnostic Tests

Diagnosing a Bartholin’s cyst may be possible by acquiring a thorough health history, performing a pelvic exam, obtaining a sample of secretions from the vagina to r/o STIs, and biopsy of the mass for women over 40 years of age (McCance et al., 2014). 

4) Sebaceous cyst:   Cysts are abnormalities in the body that contain noncancerous liquid material (McCance et al., 2014).  These cysts are mostly found on the face, neck, or torso.  Their growth is slow and is not life-threatening, but they may become uncomfortable if left untreated (McCance et al., 2014). Episodic/Focused SOAP Note Template – Assessing the Genitalia and Rectum

Signs and Symptoms

Small cysts are typically not painful.  Large cysts can range from uncomfortable to painful.  Large cysts on the face and neck cause pressure and pain.  The areas on the body where cysts are usually found include the scalp, face, neck, and back (McCance et al., 2014).

Diagnostic Tests

The clinician is able to diagnose a sebaceous cyst during the physical examination. If the cyst is seen as unusual, the clinician may order tests to rule out cancer.  The most common tests used for a sebaceous cyst include:  CT scans for a possible surgical route, ultrasounds for the internal structure of cyst, and biopsy (McCance et al., 2014).

5) Syphilis:   A bacterial infection primarily spread sexually.  It presents as a painless sore on the genitals, rectum or mouth (Hammer & McPhee, 2014).  Syphilis may spread via skin or mucous membrane contact with these sores  (Hammer & McPhee, 2014).  Post initial infection, syphilis can remain dormant for several decades before resurfacing.  Early treatment may rid the infection with antibiotics, however, when left untreated it can severely damage the heart, brain, and can be life-threatening, and maybe also passed from mother to unborn child (Hammer & McPhee, 2014).

Signs and Symptoms

Syphilis may present in different stages which may overlap at times.  The stages include:  primary syphilis, secondary syphilis, latent syphilis, tertiary syphilis, and congenital syphilis (Hammer & McPhee, 2014).

• Primary syphilis:  The first sign of syphilis is a small sore that appears at the spot where the bacteria entered the body.  This sore is also called a chancre.  The sore develops about three weeks after exposure, is usually painless and hidden within the vagina or rectum (Hammer & McPhee, 2014) .
• Secondary syphilis:  Within a few weeks of healing the patient may experience a rash that begins on the trunk and may eventually cover the entire body including the palms of the hands and soles of the feet (Hammer & McPhee, 2014).  The rash is usually not itchy and may be accompanied by wart-like sores in the mouth or genital area (Hammer & McPhee, 2014).
• Latent syphilis:  If left untreated the infection may be dormant for several years or never return.
• Tertiary syphilis:  This is considered the late stage of syphilis, the disease may damage the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints (Hammer & McPhee, 2014). Episodic/Focused SOAP Note Template – Assessing the Genitalia and Rectum

Risk Factors

• Unprotected sex
• Multiple sexual partners
• Homosexual man engaging in sex with other men
• Patient infected with HIV (Hammer & McPhee, 2014)

Diagnostics

• Serum tests can confirm the presence of antibodies that the body produces to fight infection (McCance et al., 2014).  The antibodies to the bacteria that cause the infection remain in the body for years, therefore the test can be used to determine a current or past infection (McCance et al., 2014).
• Cerebral spinal fluid. If it’s suspected that the nervous system has been compromised by syphilis a lumbar puncture may be recommended.

References

Goljan, E. F. (2014). Rapid review: Pathology (4th ed.). Philadelphia, PA: Elsevier.

Hammer, G. D., & McPhee, S. J. (2014). Pathophysiology of disease: An introduction to clinical medicine (7th ed.). China: McGraw Hill.

McCance , K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2014). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, MS: Elsevier.

Assessing The Genitalia And Rectum

Patients are frequently uncomfortable discussing with health care professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam is vital. Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to accurately assess patients with problems in these areas.

In this assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

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. Episodic/Focused SOAP Note Template – Assessing the Genitalia and Rectum

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
• 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

Assessment:

• Chancre
• PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

To prepare:

With regard to the SOAP note case study provided:

• Review this week’s Learning Resources, and 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:

Refer to Chapter 5 of the Sullivan text. 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. Episodic/Focused SOAP Note Template – Assessing the Genitalia and Rectum
• 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 the current evidence-based literature. Episodic/Focused SOAP Note Template – Assessing the Genitalia and Rectum