Posted: March 16th, 2022

Assessing the Genitalia and Rectum Episodic Note

Assessing the Genitalia and Rectum Episodic Note

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Assessing the Genitalia and Rectum Episodic Note
Subjective Portion
The subjective portion of the SOAP should include additional information. The information should describe if the patient has symptoms such as diarrhea, nausea, fever, vomiting (Bandara & Samaranayake, 2019). The patient needs to describe the internal feeling in the body, such as body weakness or dizziness. The patient should disclose if they have felt bumps in other parts of the body. It is crucial to know if the patient had had bumps in the past or during the treatment of chlamydia.
A description of the bump is essential, including the color, texture, shape, and pattern. The patient should provide information on how they discovered the bumps. For example, if they felt pain or itching experience around the genitals. Subjective information should comprise information about the medications the patient may have tried to use to treat the condition (Bandara & Samaranayake, 2019). It is crucial to provide information if any aggravating factors trigger discomfort. Rating the pain is another important aspect of the subjective portion.
Skin conditions such as bumps can occur due to a change in detergents or soap. The information is crucial since it will help determine if the soap or detergents could trigger the bump. The subjective portion should comprise information about the reproductive history, type of contraceptives, menstruation history, and obstetric history (Bandara & Samaranayake, 2019). The additional information should comprise a head-to-toe review of organs, including chief complaints, present illness, and history. The list of questions for all the organs uncovers dysfunction and hints of a disease.
Objective Portion
A comprehensive H&P includes the SOAP’s objective information, including vital signs, physical assessment, and general assessment. Additional information is necessary to uncover the aspects of the objective information (Cornelisse et al., 2020). The vital signs show that the patient’s temperature is normal, but additional information is necessary. It is crucial to know where the temperature was obtained from such as mouth, forehead, or armpit. The blood pressure is normal, but additional information is needed to know if it was taken when the patient was seated or standing. Respiratory rate should show if the patient is in distress or labored. A general assessment of the patient, including how they present in the clinic, is crucial. The information is missing HEENT assessment, including the PERRLA and EOMI. The objective portion requires information on neurological, skin, cardiovascular, and neck. The assessment should provide additional details about the cervical motion tenderness (Cornelisse et al., 2020). The additional objective information is crucial in ruling out conditions that cause bumps and determining the diagnostic tests applicable to the patient.
Assessment
Subjective and objective information should provide a logical assessment that can derive conclusions about the patient’s health condition (Cornelisse et al., 2020). An analysis of the objective and subjective information shows that it supports logical assessment. A conclusion to determine the condition requires clients to meet specific criteria. The criteria include a painful genital ulcer, clinical presentation of genital ulcer, and exclusion of other factors that can cause a painful genital ulcer (Calvo et al., 2020). The information is sufficient for supporting logical information. Additional information, both objective and subjective, is necessary for generating a reasonable assessment. The additional information is crucial in eliminating other possible conditions that can present similar symptoms. The differential diagnosis includes genital ulcer disease, genital herpes, chancroid, and donovanosis (Calvo et al., 2020). Different diagnostic tests are necessary to rule out other conditions.
Diagnostic Tests
The additional diagnostic tests necessary for the condition is a pap test. The pap test is essential since the patient has multiple sex partners (Calvo et al., 2020). She had a pap test three years ago. The Pap test will determine if she has abnormal cell growth in the cervix. Dark-field microscopy is essential to test for chancre, and syphilis chodylom latum is positive (Cornelisse et al., 2020). A physician can scrap the lesion to examine it under a microscope.
Accept or Reject Current Diagnosis
The medical history of the patient, signs, and symptoms justify the current diagnosis. I would accept the current diagnosis due to the health risks the patent is exposed to. For instance, she has multiple sex partners and a history of STI. Multiple sex partners expose a patient to the risk of chancre (Cornelisse et al., 2020). Patients can reduce risks by maintaining safety.
Differential Diagnosis
Chancre: A syphilis pore pops up where the infection entered into the body. The sore pop-ups are firm, round, and painless. The presentation is open and wet. Patients have one sore, but in some cases, patients can have more (Bandara & Samaranayake, 2019). The ulcer can go unnoticed for almost two weeks. It can heal without treatment, but quality and timely treatment us necessary (Bandara & Samaranayake, 2019). Some of the essential diagnostic tests such as blood tests confirm the presence of antibodies that fight the infection.
Condyloma Acuminatum: The condition comprises small lumps that occur as a result of sexually transmitted infections. The condition is caused by the Human papillomavirus (HPV) (Samarska & Epstein, 2019). It comprises small lumps on the genital area. It comprises a burning sensation, itching vagina or anus. Warts can go away on their own, but medical intervention is necessary to treat the condition. The disease is common among people with multiple sex partners.
Molluscum contagiosum: The condition comprises a viral skin infection. It leads to painless lumps around the genital areas. It is caused by a poxvirus that initially appears as a benign lesion (Forbat et al., 2017). The symptoms include round and fresh-colored lump. The ulcer can become red and inflamed. Patients require medical assistance to avoid deterioration of the condition. Experienced doctors will diagnose the condition by looking at the lump. Skin scrapings are necessary for the infected to determine other possible causes of the painless sores and viewing them under a microscope (Forbat et al., 2017). Treatment for molluscum contagiosum includes laser therapy, cryotherapy, and topical therapy.
Genital Herpes: The condition presents mild symptoms that can are unnoticeable for a long time. The symptoms include pain, itching, small red bumps, scabs, and ulcers (Sauerbrei et al., 2016). Pain is evident in the vagina and penis. It can trigger skin rash and genital sores. Various factors trigger genital herpes, including stress, fatigue, exposure to sunlight, and menstruation. Diagnosis for the condition includes viral culture, polymerase chain reaction, and blood test (Sauerbrei et al., 2016). Mild conditions are treated using medication such as acyclovir and famciclovir. Severe conditions require an intravenous drug.
Lymphogranuloma venereum: The condition presents unnoticeable symptoms of small painless sore and swelling of the labia. Other symptoms include painful bowel movement, discharge from the lymph nodes (Ilyas et al., 2019). It is common among heterosexuals with multiple sex partners. One of the causes of the disease is bacteria chlamydia trachomatis. The bacteria is transmitted through sexual contact (Ilyas et al., 2019). It is treated using antibiotics that facilitate healing and stop the tissue damage. Patients should seek treatment to avoid deterioration of the disease.

References
Bandara, H. M. H. N., & Samaranayake, L. P. (2019). Viral, bacterial, and fungal infections of the oral mucosa: Types, incidence, predisposing factors, diagnostic algorithms, and management. Periodontology 2000, 80(1), 148-176.
Calvo, D. F., Cassarino, D., & Fernandez-Flores, A. (2020). Syphilitic Chancre of the Lip. The American Journal of Dermatopathology, 42(10), 143-146.
Cornelisse, V. J., Chow, E. P., Latimer, R. L., Towns, J., Chen, M., Bradshaw, C. S., & Fairley, C. K. (2020). Getting to the bottom of it: Sexual positioning and stage of syphilis at diagnosis, and implications for syphilis screening. Clinical Infectious Diseases, 71(2), 318-322.
Forbat, E., Al‐Niaimi, F., & Ali, F. R. (2017). Molluscum contagiosum: review and update on management. Pediatric dermatology, 34(5), 504-515.
Samarska, I. V., & Epstein, J. I. (2019). Condyloma acuminatum of urinary bladder: relation to squamous cell carcinoma. The American Journal of Surgical Pathology, 43(11), 1547-1553.
Sauerbrei, A. (2016). Optimal management of genital herpes: current perspectives. Infection and Drug Resistance, 9, 129.
Ilyas, S., Richmond, D., Burns, G., Bowden, K. E., Workowski, K., Kersh, E. N., & Chandrasekar, P. H. (2019). Orolabial Lymphogranuloma Venereum, Michigan, USA. Emerging Infectious Diseases, 25(11), 2112.

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