Assignment: Assessing the Genitalia and Rectum Soap Note Essay Assignment Template

Assignment: Assessing the Genitalia and Rectum Soap Note Essay Assignment Template

Assignment: Assessing the Genitalia and Rectum Soap Note Essay Assignment Template

In the treatment of patients who have pathologies of the urinary and genital systems, it is crucial to know how to assess the external and internal genitalia. A comprehensive history is an essential prerequisite. Since most patients are sensitive about exposing the genitalia the attending physician should do diligence to provide the patient comfort and privacy while performing the procedure(Henderson & Herbert, 2022).The purpose of this paper is to review a SOAP note,discuss subjective and objective information that should be documented, comment on whether the diagnosis was appropriate, and discuss the differential diagnoses.

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Additional information for the Subjective Assessment

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  1. is a 32-year-old female patient who complained of urgency, increased frequency, and pain during urinationfor two days. The HPI should have included any associated signs and symptoms includingpainful intercourse, hematuria, lower back pain,fever, and per vaginal bleeding and discharge.The patient has a history of a recent sexual partner for three months. The history and number of previous sexual partners the patient had should have been included as well (Hughes &Sawleshwarkar, 2023). Upon systemic review, S. reported sleeplessness due to iliac region pain, however, the distribution of the pain was not stated. The type, pattern, and distribution of the fever should have been documented.Moreover, the systemic review ought to have included all systems of the body, especially thegenitourinary system.Since she reported that she had similar episodes in the past, the medical history of all significant previous illnesses should havebeen documented. With the presence of chronic illnesses in the family being unknown, the family, and immunization history ought to be done and documented.The social history should be documented taking note of her educational background, occupation, and living conditions, which are health determinants. Any history of tobacco use, alcohol consumption, and drug and substance use ought to have been documented.

Additional information for the Objective Assessment

Before performing a focused physical examination of the genitourinary system, a general survey should be performed. The general health condition, posture, gait, deformities, and grooming of the patient should be documented. Furthermore, a head-to-toe approach can be used, ruling out the presence of stigmata of disease, such as jaundice, pallor, cyanosis, finger clubbing, lymphadenopathy, edema, dehydration, and wasting. All body systems should be examined progressively with emphasis laid on the genitourinary system. On palpation of the abdomen, S. had tenderness of the suprapubic region. However, the bimanual pelvic examination was unremarkable. That notwithstanding, a visual examination of the external genitalia should be donechecking for skin tags, discoloration,congenital anomalies, and functional abnormalities.Additionally, the suprapubic tenderness should be expounded to describe the distribution, character, and severity (Gregory, 2019).

Subjective and Objective Information Support of the Assessment

The subjective information (urgency, frequency, painful urination, and feeling of warmth) and objective information (suprapubic tenderness and a low-grade fever of 37.3°C) support the assessment of Urinary Tract Infection (UTI). The low-grade fever is suggestive of an inflammatory process secondary to an infection. There is also a likelihood the infection is Sexually Transmitted Infection (STI)(Gaulrapp &Nührenbörger, 2022). The suprapubic tenderness may be arising from a pathology of the urinary bladder. The uterus and the adnexa are not likely to be involved because the bimanual pelvic examination had normal findings.

Appropriateness of the Diagnostics

The urinalysis,STI tests, and pap smear ordered by the healthcare provider were appropriate. The urine analysis would evaluate the presence of any infective processes in the urethra, bladder, ureters, and kidneys while testing for UTIs would assess the presence of infections in the vaginal canal, cervix, placenta, and fallopian tubes. UTIs and STIs can occur concurrently, and even be caused by the same pathogen(Peck & Shepherd, 2021). Since the patient is 32 years old, and within the incidence age for getting cervical dysplastic lesions, a pap smear should be done to rule out cervical cancer.

Acceptance of the Current Diagnosis and Differential Diagnosis

            According to the subjective and objective information of the patient gathered, I accept the current diagnosis of UTI. Albeit that, some differentials could be the cause of the patient’s illness. For example, vulvovaginitis may cause a burning painful sensation with foul-smelling discharge during urination (Marnach et al., 2022)Alternatively, pyelonephritis, would present with lower abdominal pain, fever, and hematuria (Kolman, 2019).On the other hand, considering the patient’s sexual history, she might be suffering frompelvic inflammatory disease (PID) (Ravel et al., 2021). PID may be present even if the bimanual examination was unremarkable.

Conclusion

The subjective and objective information of S. supports the assessment of UTI or STI.To make the right diagnosis, it is important to perform thorough history taking and an extensive physical pelvic examination. In addition, documentation of the findings is crucial in the holistic management of the patient. The diagnostics performed were sufficient in confirming the diagnosis of the patient. However, it is worth considering differential diagnoses such as vulvovaginitis, pyelonephritis, and PID.

References

Gaulrapp, H., &Nührenbörger, C. (2022). The Osgood-Schlatter disease: A large clinical series with evaluation of risk factors, natural course, and outcomes. International Orthopaedics, 46(2), 197–204. https://doi.org/10.1007/s00264-021-05178-z

Gregory, J. (2019). Use of pain scales and observational pain assessment tools in hospital settings. Nursing Standard, 34(9), 70–74. https://doi.org/10.7748/ns.2019.e11308

Henderson, M., & Herbert, S. (2022). Sexual history and examination in men and women. Medicine, 50(4), 205–209. https://doi.org/10.1016/j.mpmed.2022.01.003

Hughes, Y., &Sawleshwarkar, S. (2023). Sexually Transmitted Diseases: An Overview. In S. R. Prabhu, N. Wagoner, J. Hill, & S. Sawleshwarkar (Eds.), Sexually Transmissible Oral Diseases (1st ed., pp. 1–24). Wiley. https://doi.org/10.1002/9781119826781.ch1

Kolman, K. B. (2019). Cystitis and Pyelonephritis. Primary Care: Clinics in Office Practice, 46(2), 191–202. https://doi.org/10.1016/j.pop.2019.01.001

Peck, J., & Shepherd, J. P. (2021). Recurrent Urinary Tract Infections. Obstetrics and Gynecology Clinics of North America, 48(3), 501–513. https://doi.org/10.1016/j.ogc.2021.05.005

Ravel, J., Moreno, I., & Simón, C. (2021). Bacterial vaginosis and its association with infertility, endometritis, and pelvic inflammatory disease. American Journal of Obstetrics and Gynecology, 224(3), 251–257. https://doi.org/10.1016/j.ajog.2020.10.019

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The assignment for this week is an analysis of a SOAP note for the genitalia/rectum. As in the previous SOAP note analysis, this should be completed in a narrative format and answer all the questions listed in the assignment within the module.  Please remember to use the rubric to complete the assignment.

Genitourinary Assessment:

  • Subjective:
    • CC: Increased frequency and pain with urination
    • HPI: S. is a 32-year-old woman who reports that for the past two days, she has dysuria, frequency, and urgency. Has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months.
    • Medical History: None
    • Surgical History:

-Tonsillectomy in 2001

-Appendectomy in 2020

  • Review of Systems:
    • General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
    • Abdominal: Denies nausea and vomiting. No appetite
  • Objective
    • VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.
    • Pelvic Exam:

mild tenderness to palpation in the suprapubic area

bimanual pelvic examination reveals a normal-sized uterus and adnexae

no adnexal tenderness.

No vaginal discharge is noted.

The cervix appears normal.

  • Diagnostics:
    • Urinalysis
    • STI testing
    • Papsmear
  • Assessment:
    • UTI
    • STI

Using evidence-based resources from your search, 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 three different references from current evidence-based literature.

Resources :

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

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