Instructions:
Using evidence-based resources, answer the following questions and support your answers using current evidence from the literature:
-Analyze the subjective portion of the note. List additional information that should be included in the documentation.
-Analyze the objective portion of the note. List additional information that should be included in the documentation.
-Is the assessment supported by the subjective and objective information? Why or why not?
-Would diagnostic tests be appropriate for this case, and how would the results be used to make a diagnosis?
-Would you reject/accept the current diagnosis? Why or why not?
-Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using references from current evidence-based literature.
SOAP Note to be Analyzed:
GENITALIA ASSESSMENT
Subjective:
CC: I have bumps on my bottom that I want to have checked out.
HPI: AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner during the past year. Her initial sexual contact occurred at age 18. She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.
PMH: Asthma
Medications: Symbicort 160/4.5mcg
Allergies: NKDA
FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD
Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 510 WT 169lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia
Abd: soft, normoactive bowel sounds, neg rebound, neg murphys, neg McBurney
Diagnostics: HSV specimen obtained
SOAP Note Analysis
Student’s Name
Institutional Affiliations
SOAP Note Analysis
Healthcare providers need to collect comprehensive medical history from patients who visit the clinic. However, some people often shy away from sharing their symptoms with the healthcare professional whenever they are suffering from infections that affect the genitals. This makes it difficult for healthcare professionals to collect sufficient health information that is necessary for making a diagnosis (Tsevat et al., 2017). Nurse practitioners should understand the crucial information that a SOAP note should include to be considered complete. The purpose of this assignment is to analyze a SOAP note of a 21-year-old white female, a college student, who has been diagnosed with a chancre.
The Subjective Portion
The healthcare provider usually documents medical history as reported by the patient and significant others under the subjective section of the Subjective, Objective, Assessment, and Plan (SOAP) note. The subjective portion of the note includes the chief complaint (CC), history of present illness (HPI), past medical history, medications, allergies, family history, and social history. Data related to the review of systems assessment is missing in this section of the note. Health data concerning the performance or functioning of various body systems assist the healthcare provider in making a diagnosis by enabling him or her to establish a link between the symptoms and the functioning of various body organs (Dains et al., 2019). Therefore, to make the section complete, it is important to add details for the review of systems including head, eyes, ears, nose, and throat (HEENT), the cardiovascular system, neck, respiratory organs, gastrointestinal, musculoskeletal, neurological, genitourinary, psychiatric, hematologic, and endocrine systems.
The Objective Portion
The objective section of the SOAP note is usually meant for documenting information related to the results obtained following physical exams. From the given SOAP note, available objective data is that for vital signs assessment and physical exams of various organs including lungs, genitalia, abdomen, and diagnostic tests which is still incomplete. To make the section complete, it is important to add details of HEENT objective assessment and physical exam findings of the neurological, musculoskeletal, and gastrointestinal evaluation. It is important to gather data on these systems because diseases that affect reproductive organs may make patients display symptoms in other adjacent body organs (Mohseni et al., 2021). For example, urinary tract infections may cause symptoms in the genitals.
Supportive Information for the Assessment
The patient’s diagnosis that is given under the ‘assessment section’ is chancre. The subjective data, as well as the objective information, support this diagnosis. As Dains et al. (2019) explain, healthcare providers should utilize information collected during subjective and objective assessment to make an accurate diagnosis. In most cases, high incidence rates of chancre are usually recorded among sexually active youths who engage in unsafe sex with persons with the disease. Affected patients usually display symptoms including painless ulcerated sores on the reproductive organs and bumps on the patient’s bottom. Such people always report a history of a sexually transmitted disease which is a risk factor for the disease (Centers for Disease Control and Prevention, 2019). From the given SOAP note, Objective assessment has revealed a painless ulcer on the patient’s external labia. Her patient’s subjective data indicates that sexually active and has had sex with more than one partner in the past year. Other positive symptoms are the presence of bumps on her bottom and history of Chlamydia diagnosis 2 years ago.
Diagnostic Tests
Performing diagnostic tests increases the provider’s chances of making an accurate diagnosis. Diagnostic tests would be appropriate in this case considering the nature of the patient’s symptoms, medical history, and physical exams. Examples of tests that the healthcare provider can consider include urinalysis, a Pap smear test, a bacterial culture of the vaginal swab, and analysis of the Herpes Simplex Virus (HSV) specimen (Saleh et al., 2021; Berman & Schiller, 2017). Findings from these tests will support decision-making regarding whether the patient has chancre, cervical cancer, a bacterial infection, and herpes simplex thereby supporting the process of diagnosis.
Rejecting/Accepting Current Diagnosis
I would take Chancre as the correct diagnosis. A diagnosis that is supported by both the subjective and objective portion of the SOAP note should be considered accurate (Ball et al., 2019). Thereby, my rationale for accepting the current diagnosis is that it is supported by the objective and subjective portions of the SOAP note.
Differential Diagnoses
It is essential to develop a list of possible conditions that a patient might be suffering from based on the symptoms, medical history, and objective findings. The differential diagnoses for the patient include
- Chancre (primary diagnosis)
- genital herpes
- human papillomavirus
- Bartholin’s cyst
Rationale: The rationale for choosing the conditions named above as the patient’s diagnosis is that they usually cause disease symptoms that closely resemble those that are displayed by the patient described in the given SOAP note (Tsevat et al., 2017; CDC, 2016).
Conclusion
Nurses need to possess adequate knowledge for developing a complete SOAP note. From this knowledge, they will be able to analyze SOAP notes to identify missing information that should be added to make it complete. Although the subjective and objective portions of the given SOAP note are incomplete, the healthcare provider can still use it to make a diagnosis. It is appropriate to accept the current diagnosis because it is supported by both the objective and subjective portions of the note.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Berman, T. A., & Schiller, J. T. (2017). Human papillomavirus in cervical cancer and oropharyngeal cancer: one cause, two diseases. Cancer, 123(12), 2219-2229.
Centers for Disease Control and Prevention. (2019). Sexually transmitted diseases (STDs). Retrieved from http://www.cdc.gov/std/#
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Mohseni, M., Sung, S., & Takov, V. (2021). Chlamydia. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537286/
Saleh, D., Yarrarapu, S. N. S., & Sharma, S. Herpes Simplex Type 1. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482197/
Tsevat, D. G., Wiesenfeld, H. C., Parks, C., & Peipert, J. F. (2017). Sexually transmitted diseases and infertility. American Journal of Obstetrics and Gynecology, 216(1), 1-9.