The assessment of the genitalia and rectum may be uncomfortable for some patients, yet it is essential to provide a complete SOAP evaluation to determine any symptoms and associated disease that may be a vital sign to differentiate between diagnoses. In this case, a female patient presents for painless bumps on her external genitalia and explains her sensations. Upon carefully reviewing both the subjective and objective data I came to the conclusion that the patient suffers from chancre. However, not all the required information seems to be provided.
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Evaluating SOAP Note Case Study
Additional Subjective and Objective Documentation
History to be collected for this patient would include information about any sexual contacts with other partners who may be the source of the disease because the patient mentioned having more than one partner. Furthermore, the case study shows no data about the patient’s associated signs and symptoms that may be helpful in diagnostics. I would also ask about the menstrual and obstetric history along with any complications that occurred in the genital area (Ball et al., 2015). The use of any contraceptives may also provide valuable information to identify the source of the disease. Here, chapter 18 of the reading provides sufficient information about the female genitalia, which may be used to examine the case study in more detail (Ball, Dains, Flynn, Solomon, & Stewart, 2015).
As for objective data, it is possible to note that the general assessment of genitalia is presented. Nevertheless, a detailed assessment of internal genitalia is absent. According to Dains, Baumann, and Scheibel (2016), physical and diagnostic tests would include a cervix inspection and a collection of smears and cultures should be carried out. While the given case study mentions that the vaginal specimen detected herpes simplex virus (HSV), it is not stated if the patient is pregnant, uses hormones, or any prior cytology. Both ectocervical and endocervical specimens should be collected to reveal the most accurate diagnosis. The physical examination that may be used is a bimanual assessment in lithotomy position that allows properly palpating vaginal walls. The pelvic organs are to be palpated carefully to minimize uncomfortable sensations in patients.
The assessment in the case study has objective and subjective data. The patient’s information about her marital status and the number of sexual partners is mentioned as well as the results of laboratory tests to come up with the diagnosis of the chancre. It seems that the implementation of the additional points may improve and detail the process of the patient examination. Most importantly, by aligning any side symptoms and history notes to bumps reported by the patient, it is possible to consider a wider variety of diseases, as noted by Sullivan (2012). For instance, Genital Human Papillomavirus (HPV) is closely associated with early sexual contact and abnormal cervical cytology. Other diagnostic tests may include culture specimen, blood tests such as CBC and ESR, as well as further laparoscopy to take the biopsy from the suspected bumps.
Considerations Regarding Current Diagnosis
The results of the tests would be used to make a diagnosis by assessing them and eliminating diagnoses that do not have similar symptoms. The diagnosis identified in the case study seems to be appropriate, yet it is essential to investigate some differential diagnoses:
- Chancre. After the infection incubation, the period of primary syphilis begins with the onset of chancre – a typical syphilitic symptom (Janier et al., 2014). The primary chancre first presents a red bump on the skin or mucous membrane, and then it turns into erosion. Chancre with syphilis has its peculiarities such as a limited area of localization, a lack of impact on internal organs, and a positive prognosis of recovery. All symptoms align with the patient’s assessment and the presented symptoms.
- Genital herpes. It is a sexually transmitted viral infection that is characterized by a rash in the form of grouped vesicles on the skin and mucous membranes of the genitalia (Chelimo, Wouldes, Cameron, & Elwood, 2013). Primary herpes can be asymptomatic or with severe manifestations of the disease. It initially manifests itself as symptoms of local inflammation, including redness, swelling, pain, burning, or itching in the area of infection. As there are no complaints or signs of pain or swelling, this diagnosis can be eliminated.
- Genital warts. Caused by HPV, papillomas can be located on the mucous membrane of the genitals along with the inguinal and pubic regions. Genital warts in women combined with frequent changes in sexual partners can cause cervical cancer (Chelimo et al., 2013). Pathology can proceed without special signs, and discomfort can arise only during sexual intercourse. The patient does not mention any discomfort, although additional tests mentioned above can help support or eliminate this diagnosis.
- Vaginal eczema. The symptoms of the acute form of eczema appear in the zone of labia majora. In addition to the rash but not pain, it may be complicated by itching, because of which the bumps are constantly damaged, leaving behind erosion and peeling (Van Onselen, 2013). Eczema has the property of progressing and, if the treatment is not started on time, it will spread from the area of labia majora to the skin of the labia minora, the clitoris, the pubis, the perineum, and the anus. The patient does not report any itching or progressing of the bumps. This diagnosis can be eliminated as the bumps do not appear to be damaged in any way.
- Lymphogranuloma venereum. The patient may have the incubation period of this disease. After 1-4 weeks, regional lymph nodes increase, as a rule, in the small pelvis (Vries, Zingoni, Kreuter, Moi, & White, 2015). It is important to stress that the affected lymph nodes, in this case, are dense, painful, and weld together. The skin above the nodes acquires colors from pink to cyanotic red. This diagnosis may require additional tests to be eliminated or supported.
All in all, the diagnosis of chancre seems to be the most appropriate because of described symptoms. However, I believe that diagnostics may be needed for this case as the patient’s information is insufficient to make a concrete conclusion. Differential diagnoses should be considered.
In conclusion, it should be stressed that this case study was important to understand how to assess female patients’ genitalia and differentiate between the related diagnoses. The review of the presented objective and subjective data allowed making sure that everything is included to provide the patient with high-quality care. The absence of some history and diagnostics made it possible to consider adding more relevant data and contributing to a comprehensive patient examination. All in all, it is essential to state that such assignments provide the opportunity to observe any lacking information and come up with the decisions to address them.
The given case study presents the examination of a 21-year-old female patient, who is concerned about bumps on her genitalia. The combination of the subjective and objective data shows that she had several sexual partners and was previously diagnosed with chlamydia that was successfully treated. The patient assessment is incomplete, and additional physical exams and laboratory tests are needed. The analysis reveals the following differential diagnosis: chancre, genital herpes, genital warts, vaginal eczema, and lymphogranuloma venereum. The review of the mentioned diagnoses shows that the initial decision can be accepted but additional tests may help support it.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Chelimo, C., Wouldes, T. A., Cameron, L. D., & Elwood, J. M. (2013). Risk factors for and prevention of human papillomaviruses (HPV), genital warts and cervical cancer. Journal of Infection, 66(3), 207-217.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Janier, Á., Hegyi, V., Dupin, N., Unemo, M., Tiplica, G. S., Potočnik, M.,… Patel, R. (2014). 2014 European guideline on the management of syphilis. Journal of the European Academy of Dermatology and Venereology, 28(12), 1581-1593.
Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis Company.
Van Onselen, J. (2013). Eczema: A common skin condition in older people. Nurse Prescribing, 11(4), 165-173.
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Vries, H. J. C., Zingoni, A., Kreuter, A., Moi, H., & White, J. A. (2015). 2013 European guideline on the management of lymphogranuloma venereum. Journal of the European Academy of Dermatology and Venereology, 29(1), 1-6.