SOAP Note and Differential Diagnoses

 
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SOAP Note and Differential Diagnoses

SOAP 1

Name:  G.B. Date: 2/14/2017 Time: 0900                         Encounter ID: 37455664
Ethnicity: African American Age: 36 Sex: Female
SUBJECTIVE
CC: “I am here today for woman general health examination due to rough but painless bumps on the pubic region.”
HPI:

G. B. is a 36-years-old female who has come to the clinic complaining of rough but painless bumps on the external genitalia. The patient notes she has not experienced cases of abnormal virginal discharge. However, she states that she is not aware of the period, which the bumps have existed since she only noticed them a week ago.

Medications:
PMH: Chlamydia diagnosed two years ago but effectively treated

Allergies: no history of allergy

Medication Intolerance: None

Chronic Illness/Major traumas: None

Chronic Health Problems: HSV, bacterial vaginosis

Hospitalizations/Procedures: The patient states she has not had any major surgical procedure and denies any recent hospitalization.

Family History: 

Father: diabetes mellitus, hypertension, and dementia

Mother: chronic kidney stones and hypertension

Siblings: brother has asthma

Grandparents: no health records found

Social History:

Occupation: clerk at a local store

Marital Status: the patient lives with her long-term male partner

Children: she has two children a boy 15 years old and a girl 13 years old.

Birth control: condom

Exercise: the patient rarely engages in physical exercises

Tobacco and Alcohol Use: she denies alcohol consumption and cigarette smoking

Substance abuse history: patients states she has never been involved in drugs abuse

Safety assessment: the patient feels that her home provides the necessary social support and environmental safety

ROS
General

The patient denies night sweats, weight loss, weight gain and fever

Cardiovascular

She does not experience any chest pain, palpitations, bruits, and edema.

Skin

No bruises, lesions noted

Denies any bruising or cuts to the skin.

Small bump detected on the external genitalia

Respiratory

The patient is free from shortness of breath and does not experience wheezing, coughing, and dyspnea.

Eyes

The patient does not suffer from eye problems including pain, redness, and blurred vision.

Gastrointestinal

She has not experienced incidences of abdominal pain, diarrhea, nausea, vomiting, and heartburn

Ears

No abnormal discharge detected in the ears, and the patient does not suffer from ear pain or hearing loss

Genitourinary

The patient denies increased urinary urge and frequency

She does not have hematuria, abdnormal

However, she has vaginal discharge and experiences pelvic pain

She states she is sexually active and has had sex with another person in the last two weeks though she used a condom

No missed menses, normal flow.

Nose/Mouth/Throat

she denies dryness of the mouth, hoarseness, and throat pain

Musculoskeletal

She denies muscle pain, joint swelling and back pain. She has not experienced incidences of decreased range of motion

Breast

The patient denies changes in breast appearance or presence of lumps.

Neurological

Denies seizures, numbness, lightheadedness, instability, vertigo, and loss of memory

Heme/Lymph/Endo

She denies a history of diabetes, easy bleeding, lymph node tenderness, excessive hunger, and thirst as well as heat and cold sensations

Psychiatric

Denies depression, sleeping difficulties, and acute distress

OBJECTIVE
Weight 154 lbs      BMI 26.3 Temp 98.7 Orally BP 111/66
Height 5’4” Pulse 83 Resp 17
General Appearance

The patient seems well nourished, conscious and alert with no signs of acute distress

Skin

Besides being warm to the touch, the skin is dry and intact with no bruises, lesions, and clubbing. Skin is also free of rashes, redness, and inflammation. Tiny bumps detected on the external genitalia.

HEENT

Head: no head abnormalities, bald spots, and scalp tenderness detected

Eyes: Conjunctiva appears pink. No abnormal discharge and drainage detected. PERRLA examination, Extraocular muscles test, as well as corneal light reflex are normal.

Ears: Both ear canals are open and bilateral tympanic pearly is grey.

Nose:  Nostrils are open with no abnormal discharge and septal deviation

Throat: Mucus membranes are moist and free of lesions, redness, inflammation, and tonsils.

Neck:  she is free of thyromegaly, and demonstrates full range of motion; no lymph tenderness detected

Cardiovascular

The patient does not have irregular S1 and S2 rate and rhythm as revealed through auscultation.

No S3 or S4 noted.  She also does not have abnormal sounds, murmurs or rubs

Respiratory

Chest expansion is symmetrical. Respiration 17/min, easy and regular,

Auscultation reveals bilateral lung sound is clear, and the patient does not present with shortness of breath.

Gastrointestinal

The patient does not have masses, and hepatosplenomegaly; the abdomen is soft and not distended with bowel sounds present in all quadrants

Breast

Breast examination does not reveal any masses, lumps, and pimple discharge

No abnormal breast enlargement detected

Genitourinary/Gynecological

The patient has multiple lesions forming a confluent mass on the external genitalia, warts, which are broad based are soft and non-keratinized; no bladder tenderness or dullness on the area above the symphysis pubis. Abnormal discharge not detected. The uterus is retroverted, and the cervix is normal. No enlargement of the lymph nodes in the inguinal region detected.

Musculoskeletal

The patient does not experience joint pain and stiffness as well as decreased range of motion.

She also presents with a full range of motion. No cyanosis bruises or crepitus detected.

Neurological

The patient walks normally and assumes normal gait; her speech is clear and answers questions properly.

Psychiatric

Cooperative and she is alert and maintains eye contact besides being cooperative

Lab Tests

Urinalysis

Urine yellow in color and free from deposits

SG=1.010, pH=7.0, UBG=0.2

Colonoscopy: bumps detected on the skin

Pap smear– results pending

Gonorrhea– results pending

Blood tests:

CMP, CBC, TSH, antibodies and Vit D level

Special Tests

No special tests done

 ASSESSMENT FINDINGS AND PLAN
Primary diagnosis:

Human pappilomavirus – The typical symptom of this condition is the presence of small persistent bumps on the external genitalia (Germain, 2013).

Differential Diagnosis:

Genital herpes – This condition is typified by small blisters on the genitals as well as on the vagina

Chlamydia – The first sign of Chlamydia infection is the presence of painless soles around the genitals (Germain, 2013).

Genital sores – The main symptom of genital sores is the presence of red bumps on the genital area

Chancroid – the presence of small red bumps on the genitals may also lead to a diagnosis of chancroid (Warren, 2009).

PLAN:

Further Testing:

Viral Culture-using scrapings of the bumps

Medication:

Sinecatechins to be applied topically on the affected areas

Education: The patient should be advised to limit the number of sexual partners, avoid tight undergarments, and minimize the application of creams and lotions that might worsen her condition. A high hygiene level should be maintained (Woods, 2002).

Return to office:  a 2 month Follow up for re-evaluation is appropriate for the patient

Patient to be called to collect pap smear and gonorrhea results

Evaluation of patient encounter:

The patient responded positively to interview questions

In the future, I will include a counselor to ensure that patients presenting with similar conditions open up on issues relating to sexuality.

 

 

 

 

 

Soap 2

Name:  J. M. Date: 02/14/2017 Time: 0800

Encounter ID: 37645664

Ethnicity: African American Age: 28 Sex: Female
SUBJECTIVE
CC:” I am here for foul odor vaginal discharge.”
HPI:

J. M., a 28 years old female, has visited the facility complaining of foul odor vaginal discharge especially following sexual intercourse. The patient also complains of burning sensation during urination. The patient states that the vaginal discharge, which she describes as thick, fouls smelling slimy discharge began about a week ago. She also complains that at times she experiences a burning sensation during urination.

Medications: Menstrin- 28-day pack
PMH: she was diagnosed with asthma in her childhood, the condition has been resolved, and she does not take asthma medications anymore

Allergies: extreme cold leads to asthmatic symptoms

Medication Intolerance: None

Chronic Illness: None

Hospitalizations/Procedures: Patient denies any surgical operation or recent hospitalization.

Family History: 

Father: gastrointestinal reflux disorder, hypertension

Mother: she does not have a significant medical history

Siblings: brother asthmatic

Grandparents: no records of health information available

Social History:

Occupation: the patient is a nursing student

Marital Status: she lives in an apartment near campus with her long-term male partner

Birth control: she does not use condoms; she uses oral contraceptives

Exercise: the patient engages in regular physical exercises including running and jogging for thirty minutes every day

Tobacco use and alcohol consumption: the patient takes alcohol and smoke cigarettes socially

Substance abuse history: she has never abused illegal substances

ROS
General

She denies changes in mood, appetite, and weight.

Cardiovascular

the patient does not have a history of cardiac disorders; she denies pain in the chest, irregular and racing heartbeat, and irregular pulse

Skin

She denies skin abnormalities, lesions, and rashes as well as ulcerations

Respiratory

She does not experience shortness of breath, wheezing and coughing

Breast

No breast abnormality, discharge, tenderness, and mass.

Gastrointestinal

The patient does not experience nausea and vomiting, abdominal pain and changes in bowel pattern.

Musculoskeletal

She denies muscular pain, arthritis, joint swelling, and pain.

Genitourinary/Gynecological

The patient does not have a history of vaginal discharge; she denies vaginal itching but complains of painful sensation during urination and foul smelling vaginal discharge

 Neurological

Denies syncope, disorientation, and seizures

She also denies inappropriate gait, anxiety, and difficulty in concentration

Psychiatric

The patient has been experiencing mild depression

OBJECTIVE
Weight 139 lbs      BMI 23.9 Temp 99.7 Orally BP 121/80
Height 5’3” Pulse 67 Resp 14
General Appearance

The patient is a 28 years old African America female who appears well nourished, and well developed. She is in no acute distress.

Skin

The patient’s skin is intact, dry and warm to the touch; the skin is also free of lesions and rashes

HEENT

Head:  No head abnormalities detected, Hair is healthy and well distributed. No bald spots identified

Eyes: visual fields are intact, and the conjunctiva is pink;

Ears: Free from ear pain and tenderness; Bilateral tympanic pearly grey; the ears canals are open

Nose:  no discharge  noted

Throat: Tonsil absent, dentation intact lesions, no exudate noted, Oral mucosa and Mucous membranes pink and moist; no inflammation of epiglottis noted

Neck:  No thyromegaly, lymphadenopathy or nodules noted

Cardiovascular

S1 and S2 present. Regular heart rate and rhythm noted; no murmurs rubs or gallops detected

Pulmonary

Chest excursion normal; auscultation reveals normal breath sounds; patient does not experience shortness of breath

Gastrointestinal

Active bowel sounds detected, abdomen soft and non-tender; no palpable masses.

Genitourinary/Gynecological

No abnormalities detected in the urethral meatus; vaginal mucosal is slightly reddened; thick tan smelling discharge noted; lower pelvic tenderness detected; no uterine abnormalities detected

Musculoskeletal

Range of motion is within the normal limits; no joint swelling, tenderness, and pain; free of edema and cyanosis

Neurological

The patient is oriented and has steady gait; her speech is clear

Lab Tests

Urine test for pregnancy

Urinalysis

Cervical swab culture

Pap smear

Special Tests

None

 ASSESSMENT FINDINGS AND PLAN
Primary Diagnosis: Bacterial vaginosis: the patient presents with fouls smelling vaginal discharge, which is a typical symptom of this disorder (Center for Disease Control and Prevention, 2014).

Differential Diagnosis:

Urinary tract infection: there is a possibility of UTI since this condition is characterized by painful sensation during urination, and strong smelling urine; however, urine dipstick was negative, and the patient does not have urethral inflammation and urethral meatus discharge (Germain, 2013).

Chlamydia: pain when urinating, abnormal vaginal discharge, painful sensation during sex, an itching sensation around the vagina (Germain, 2013)

Naisseria gonorrheae: The main symptoms of this condition is foul-smelling vaginal discharge;

Plan:

Further Testing: TSH to detect thyroid gland abnormalities

Medication: The patient to be administered with Flagyl 500 mg PO twice daily for seven days.

Education:

The patient should be advised to adhere to the medication regime;

It is essential that the patient avoids douching since it disrupts normal balance in the vagina. The patient should avoid feminine hygiene sprays and perfumed soap that irritates the vagina (Greene, 2011).

Return to office:  Follow-up in a week’s time or as needed.

Evaluation of patient encounter:

The patient responded positively to the interview questions;

 

References

Center for Disease Control and Prevention. (2014). Bacterial Vaginosis – CDC Fact Sheet. Retrieved from http://www.cdc.gov/STD/bv/STDFact-Bacterial- Vaginosis.htm

Greene, C. D. (2011). Permanently Beat Bacterial Vaginosis: Proven 3 Day Cure for Bacterial Vaginosis Freedom. Atlanta, Georgia: Women’s Republic.

Germain, A. (2013). Reproductive tract infections: Global impact and priorities for women’s reproductive health. Boston, MA: Springer.

Warren, T. (2009). The Good News about the Bad News: Herpes, Everything You Need to Know. New York, NY: New Harbinger Publications

Woods S., (2002). Everything You Need to Know About Std-Sexually Transmitted Disease. New York, NY: The Rosen Publishing Group

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