Assignment 1: Assessing the Genitalia and Rectum

Introduction

SOAP is an acronym for the subjective, objective, assessment, and plan method used in documenting notes in the patients’ chart accompanied by other standard formats like the admission note. This task sets out to analyze the SOAP notes for the case study based on the evidence provided. Assignment 1: Assessing the Genitalia and Rectum

Chief Complaint (CC): Genitalia Bumps

The patient is a 21-year-old female who looks awake and alert, and even appears healthy and looks her indicated age. She came to the facility with complaints of bumps on her genitalia. She observed the bumps on her genitalia but was not sure how long they had been there, though she confesses to being sexually active. She says to have had a history of STI in the name of chlamydia which was adequately treated. She also admits that she had multiple sex partners with whom she could have sex without protection. She has neither vaginal discharge nor dysplasia (Jacobson, 1950).

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Treatment: Symbicort 160/4.5mcg needed for the treatment of the bumps

Allergies: NKDA

Past Medical History: Asthma

Family History: No history of cervical or breast cancer.

Social: the patient denies any tobacco use, nor exposure to tobacco. She is sexually active with multiple sex partners. She does not reveal the use of condoms. She is married and with three children, a girl and two boys.

There are various reasons for the presence of bumps in the genitalia. Among them is the possibility of bad hair removal method, due to Bartholdi’s cyst or even due to the presence of genital warts. Other reasons could be that the patient may have a sebaceous cyst or genital herpes (Jacobson, 1950) Assignment 1: Assessing the Genitalia and Rectum.

Purpose Statement

Assessment:

Lab/Test: differential lab tests should be carried out to confirm or rule out the possibility of an infection

Differential Diagnosis (DDx): Bartholin Cysts, Chlamydia, Genital Warts

Review of Systems

Constitutional: The patient was well composed and oriented, was also very alert.

HEENT: the patient’s head was normal, never experienced cases of a headache, and had no vaginal discharge. The patient had no visual problems, and there were no records of hearing impairments (Jacobson, 1950).

Cardiovascular: she had no palpitation, had no murmurs, and no edema

Respiration: the patient had no coughing or wheezing, was negative for sneezing.

Breast: had no breast discharge, no nipple lumps.

Psychiatric: the patient was in distress but had no suicide attempts.

Diagnostic Test

By the physical examination and the symptoms exhibited by the patient, the physician was able to make a precise diagnosis for Bartholin Cyst. Nonetheless, a bacterial culture and differential test was recommended to back up the physical examination test judgment arrived at by the physician so that they could be able to rule out some differential diagnosis (Perti, Brown, & Wald, 2013). The bacterial culture tests entail scrapping off of the swellings on the genitalia and subjecting them to assessment in the lab for the presence of E. coli (Mungan, Uğur, Yalçin, Alan, & Sayilgan, 1995)Assignment 1: Assessing the Genitalia and Rectum.

The test was positive for the bacteria that causes Bartholin cyst.

Assessment

There was no doubt that the patient suffered from genital infection given the symptoms that she exhibited. After review of the presented symptoms, plus the evaluation of the laboratory results, the physician came up with some diagnoses (Perti, Brown, & Wald, 2013). Firstly, the patient admitted to having multiple sexual partners, a probable cause of the present condition. She has painless sores and blisters in her genitalia but lacks vaginal discharge. She also presented a history of chlamydia and hence the conclusion. With the critical information, the physician concluded that the patient had Bartholin’s Cyst (Mungan et al. 1995).

Treatment

The physician recommended that the patient is subjected to a biopsy to check for the possibility of cancerous cells as evidenced by the presence of the healed swollen scar on the genitalia of the patient. Sitz baths and antibiotics were recommended as sources of treatment. The patient was aware that there was no cure for the Bartholin’s cyst, save for surgical operations. Therefore, sitz baths were the best option (Omole, Simmons, & Hacker, 2003).

Summary

Having such illnesses as Bartholin’s cyst can be very traumatizing, and the people can become aloof as well as distressed. It is important that the physician advises the patient to accept the condition. It is also vital for the physician to advise the patient to communicate effectively with her partners and advise them if they could also seek medical attention because the condition can stay dormant in the body for an extended period (Omole, Simmons, & Hacker, 2003) Assignment 1: Assessing the Genitalia and Rectum.

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The patient should also be alive to the fact that having multiple partners is a recipe for an increased risk of contracting infections and reducing the number of sexual partners would help mitigate the risks. It is also important for the physician to advise the patient to stick to the given guidelines for the bumps to heal (Wechter, Wu, Marzano, & Haefner, 2009). Notably, it is useful for the patients to open up about their sexuality, although it might appear awkward, people need to be honest, a fact that ought to be clear for the patient. Finally, this task advice that the only single way guaranteed of avoiding such infections is through abstaining or sticking to a lifelong single partner.

Follow Up

The patient was advised to stick to the prescriptions for the duration stated and report back for the monitoring of the healing progress.

References

Jacobson, P. (1950). Vulvovaginal (Bartholin) cyst treatment by marsupialization. Western Journal of surgery, obstetrics, and gynecology, 58(12), 704.

Mungan, T., Uğur, M., Yalçin, H., Alan, Ş., & Sayilgan, A. (1995). Treatment of Bartholin’s cyst and abscess: excision versus silver nitrate insertion. European Journal of Obstetrics & Gynecology and Reproductive Biology, 63(1), 61-63.

Omole, F., Simmons, B. J., & Hacker, Y. (2003). Management of Bartholin’s duct cyst and gland abscess. American family physician, 68(1), 135-140.

Perti, T., Brown, J. M., & Wald, A. (2013). Genital Herpes. In Women and Health. Elsevier Inc.

Wechter, M. E., Wu, J. M., Marzano, D., & Haefner, H. (2009). Management of Bartholin duct cysts and abscesses: a systematic review. Obstetrical & gynecological survey, 64(6), 395-404 Assignment 1: Assessing the Genitalia and Rectum.

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