Health Assessment

 

Case Study for Evaluation (This is all the in the SOAP note)

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 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, negMcBurney
  • Diagnostics: HSV specimen obtained

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.