Assessing Genitalia and Rectum SOAP NOTE

AssessingGenitalia and Rectum

SOAPNOTE

SUBJECTIVEDATA

Patient`s Melisa Hays

Age:21

Gender:Female

Ethnicity:Caucasian

Historyof Present Illness: Melisa Hays, a 21-year-old college student,visited our clinic complaining about external bumps on her genitalarea, claiming that the bumps are painless and feel rough. Thepatient is sexually active and claims she has involved in sexualintercourse with more than one partner in the past year. The patientcomplains of no abnormal vaginal discharge. She is unsure how longthe bumps have been there but noticed them about a week ago.

MedicalHistory (past): The patient states she once contracted a sexuallytransmitted disease (chlamydia) about two years ago, but states shecompleted the treatment as prescribed. She further claims her lastpap smear exam was three years ago, but no dysplasia was found. Theresults turned normal.

SurgicalHistory: None

AllergyHistory: None.

SocialHistory: The patient reported that she is sexually active and has hadmore than one lover over the past year. She also stated that sheenjoys going out with her friends during the weekends and taking afew shots of whisky.

FamilyHistory: Hays reported that most of her family members were healthy.She stated that her father worked at the local bank as an accountant,and had no case of any terminal illness. Her mother was a lawyer, whoenjoyed morning jogs, and also did not suffer from any terminalillness. Her younger sister, however, had eye problems, but had beencorrected by the optician: she wears glasses.

PsychosocialHistory: Hays said that she has had more than one lover over the pastone year and became sexually active at age 18.

Reviewof System (ROS)

HEENT:No symptoms

Cardiovascular:No symptoms.

Respiratory:No symptoms

Gastrointestinal:No symptoms

Genitourinary:Hays complained of itchiness in her vagina but reported that nodischarge was dispelled.

Musculoskeletal:No symptoms

Psychiatric:Hays feels that the symptoms of her ailment are embarrassing.

OBJECTIVEDATA

GeneralPhysical Examination: The patient is a 21-year old student who iscooperative and fairly easy to work with.

Skin:Bumps and itchiness in her vaginal area.

VitalSigns: Temp 98.1 degrees Fahrenheit: BP 120/80 mmHg: Pulse 77 resp

HEENT:The patient`s head is Normocephalic. Her pupils are also equal andreactive to light. Also, no swelling was noticed on her externalauditory canal – it is patent. Her nares are also patent laterally.Her dentition is also quite impressive: her gums are pink.

Chestand Lung: Her breath is smooth: she has no difficulty breathing.

Cardiovascular:Her heart rate is fairly regular – her distal pulse is +2, and nomurmur can be detected. Peripheral edema has also not been noted.

Abdomen:No masses, distention or organomegaly have been noted – her abdomenis soft and tender. Her bowel sound is also present and to allquadrants.

Musculoskeletal:Her arms and knees are in good shape. She can move them with ease.

Neurological:The patient`s alert level is ×4. However, the bumps on her vaginaworry her a lot.

ASSESMENT:Genital Warts

GenitalWarts. This ailment is caused by the Human Papilloma Virus (Mannasievand Whitehead, 2004). Women who are under age 25, who are sexuallyactive, are susceptible to HPV. Warts that manifest outside thegenitals are indicative of non-cancerous HPV. Hays should be referredto a gynecologist for further investigation on the specific type ofHPV she is infected with.

DifferentialDiagnosis:

Chlamydia.This infection does not show its symptoms for many women, and it`snot curable in some cases.

Genitalherpes. Some of the symptoms of this disease are the existence of thered bumps that are painless.

Gonorrhea.These infections are very common to women who engage with more thanone partner, and they show mild symptoms among most women.

Syphilis.The symptoms of syphilis are symptomatic of other ailments. Thedisease is also manifested by wounds that look like painless bumps, apainless sore, or a zipper cut.

Nevi.These are moles that have a dark appearance and are usually raised.

PLAN

Acomprehensive vaginal examination will be done on the patient. Duringthe exam, the doctor will examine her vulva, looking for redness,sores, irritation, swelling, or any other abnormality. Afterward, thedoctor will use a speculum to examine the inner part of the cervixand the vagina. A pap smear test will also be done before removingthe speculum.

ABimanual exam will also be carried out, where the doctor will inserttwo gloved fingers (lubricated) into the patient`s vagina using onehand while the other presses on the outer part of the lower abdomengently.

Afew questions will also be asked:

Havehad a sexually transmitted infection before? If yes, when?

Haveyou had any surgery?

Whatailments affect your family?

Haveyou ever had fibroids or cancer before?

Othertests will also be conducted to establish the true cause of thedisease: blood tests.

Medication:

Apply[Topically] Podophyllums resin – Pod-Ben-25 – on the affectedarea.

InjectHays with Interferon alpha n-3

AdministerPodofilox (Condylox) to the patient to apply on the affected areatwice a day while at home

Devices:None

Therapy:None

Recommendations

Thepatient will be made aware of the factors that precipitate theoccurrence of the Human Papillomavirus to prevent it from recurring,after treatment. She will be advised to avoid sex until all hersexual partners have been tested and treated if they suffer from thesame disease. She will also be advised to avoid all types of sexualencounters, including oral and anal, until treatment is over, so asto avoid reinfection.

References

Ball,&nbspJ.,Dains,&nbspJ., Flynn,&nbspJ., Solomon,&nbspB., &amp Stewart,&nbspR.(2014).&nbspPhysicalExamination and Health Assessment Online for Seidel`s Guide toPhysical Examination.Mosby Inc.

Bates,&nbspB.,J.B. Lippincott Company, &amp Jacoby/StormProductions.(1982).&nbspFemalegenitalia, anus &amp rectum.Philadelphia, PA: The Company.

Manassiev,&nbspN.,&amp Whitehead,&nbspM.&nbspI. (2004).&nbspFemalereproductive health.New York: Parthenon Pub. Group.

Sullivan,&nbspD.&nbspD.,&amp Sullivan,&nbspD.&nbspD. (2012).&nbspGuideto clinical documentation.Philadelphia: F.A. Davis Co.