A SOAP note is used by the physician to detail the objective and subjective information concerning the health of a patient. It is important as it helps the physician to determine the course of action that will lead to an improvement of the health of a patient (Lee, Rouleau & Longmuir, 2016). In AB's case, she has bumps on her bottom that are painless and rough, she has not experienced vaginal discharge, and she contacted chlamydia 2 years ago but it was treated successfully. Analyzing this SOAP note will help to determine the possible health conditions affecting AB to pave way for appropriate medical interventions.
AB brings forward a subjective concern that she has developed bumps on her bottom that need to be examined. She has no information concerning the duration over which she has had the bumps. The subjective matter also indicates that she has no idea what the bumps could be. There are numerous health concerns that could lead to the formation of bumps on the genitalia. These could be fungal infections or Sexually Transmitted Infections (STIs). Examples of STIs include thrush, genital warts, and herpes. The physician should gather more information on the extent, size, and color of the bumps to help determine with certainty what they could be. Concerning her past medical history, she says she has had an encounter with asthma and chlamydia. AB should state whether she has suffered from other STIs. The physician needs to find out whether she has suffered from skin infections, possible surgeries she has experienced in the past, and possible injuries to the vagina in the past.
From the objective portion, it has been established that AB's heart has RRR without murmurs. It may be crucial if the physician checked for the presence of peripheral pulses. This is important to find out the seriousness of the health condition she is experiencing. The analysis of the lungs indicates a symmetrical pattern between the chest walls and CTA. However, it may be necessary to gather more information concerning any kind of wheezing and nasal flaring. This could help to determine whether her asthma could be a factor in her health condition. Concerning her genitalia, the physician notes that the distribution pattern of her hair is normal and no masses or swellings could be identified on the hair follicles. Taking a pap smear would be recommendable at this point considering that it has been 3 years since the procedure was done and she has contacted chlamydia in between that period. During this procedure, I will have to examine her uterus, cervix, and ovaries. I will also take note of any form of discharge, foul smell, or bleeding of the vagina.
I will use both the objective and subjective information to support this assessment. The subjective portion of information has a number of questions that the physician has to answer. In that regard, these questions will be important in showing the physician what approach would be the best in dealing with the situation. The objective portion provides a list of conditions that the physician should not consider. It would be appropriate to carry out diagnostics as this will help to determine whether the health concern is related to a fungal infection or an STI. The result will be used in the determination of the specific health problem affecting the patient. Considering the accuracy and consistency of procedures used in the assessment of the health problem, accepting the current diagnosis would be a good option.
3 Possible Conditions
Scabies is one of the conditions that could be considered a differential diagnosis for AB. The skin of patients with scabies normally shows inflamed papules (Van Gysel, 2016). This health condition can affect any body part including the genitalia. It can also lead to itching of the genital area, especially during the night. The presence of swellings on AB's genital area could be proof that she has scabies.
She could also be suffering from another instance of chlamydia because of little discharge on from her vagina. It is possible that the discharge passes unnoticed because she does not mention the problem of vaginal discharge. Chlamydia is usually asymptomatic hence it may not lead to itching or pain (Geisler, 2015). AB denied feeling any form of pain or itching in her genital area.
It is also possible that AB has contracted syphilis. This health condition is mostly associated with painless papules (Van Gysel, 2016). AB denies feeling pain on her bumps hence there is a possibility that she is suffering from syphilis. Further tests will be necessary to determine the specific health condition affecting her in order to take appropriate measures to remedy the situation.
The SOAP note has provided adequate information to help determine the possible health conditions that AB affecting AB. It has provided objective and subjective information that is crucial to tap into the knowledge base of the physician to help him come up with the most appropriate medical intervention. However, the physician should have determined the color and size of the bumps make the assessment more specific. Overall, the SOAP note provided basic information that will help to remedy the condition.
Geisler, W. M. (2015). Diagnosis and management of uncomplicated chlamydia trachomatis infections in adolescents and adults: summary of evidence reviewed for the 2015 centers for disease control and prevention sexually transmitted diseases treatment guidelines. Clinical Infectious Diseases, 61(suppl_8), S774-S784.
Lee, A. G., Rouleau, J., & Longmuir, R. (2016). Controversies in neuro-ophthalmology. CRC Press. Van Gysel, D. (2016). Infections and skin diseases mimicking diaper dermatitis. International journal of dermatology, 55, 10-13.
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