Analysis of a Focused SOAP Note on Genitalia Assessment.
Episodic/Focused GENITALIA ASSESSMENT note
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.Analysis of a Focused SOAP Note on Genitalia Assessment.
Medications: Symbicort 160/4.5mcg
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)
VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; 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.Analysis of a Focused SOAP Note on Genitalia Assessment.
Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, neg McBurney
Diagnostics: HSV specimen obtained
Using current evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.
A) Analyze the subjective portion of the Episodic/Focused Genitalia Assessment note. List additional information that should be included in the documentation.
B) Analyze the objective portion of the note. List additional information that should be included in the documentation.Analysis of a Focused SOAP Note on Genitalia Assessment.
C)Is the assessment supported by the subjective and objective information? Why or why not?
D) Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
E)Would you reject/accept the current diagnosis? Why or why not?
F)Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.Analysis of a Focused SOAP Note on Genitalia Assessment.
Address one of the six key areas of health care discussed in the ANA Social Policy Statement. Explain how you will shape the future for nursing to fulfill nursing’s social responsibilities.
The support we give to society is a significant part of nursing profession. As nursing continues to evolve, in order to satisfy the needs of all, we must all be mindful of our vital position within the society. For the length of their career, the ANA has striven to include exclusive guidelines for nurses to adopt. In 2010, the ANA issued a statement on nursing social policy, “… which articulates the aspects in which contemporary nursing is valued as a discipline within U.S. culture and is solely responsible to that society” (Neuman, 2012). (Neuman, 2012). In the declaration, the ANA addresses six main areas: 1) quality health care organization, implementation, and funding, 2) public health provision, 3) enhancement of nursing and healthcare expertise and effective use of technologies, 4) expansion of healthcare services and health policy, 4) expansion of healthcare resources and support policy, 5) Definitive health policy and legislation preparation, and 6) Duties under serious circumstances. Provision for the Welfare of the People is the one main area I want to work on.Analysis of a Focused SOAP Note on Genitalia Assessment.
Provision for the welfare of the people defines the duty of nurses to provide education to members of society within the Declaration. Serving in a clinical environment as a pediatric nurse, I constantly give my patients and their families’ awareness of their healthcare. Nurses do everything at our clinic. We test telephone calls, administer vital injections, and perform operations such as catheters, suture removals, pleurodesis, and IV insertion. We teach curative measures, procedural metrics, and preventive medicine during our day.Analysis of a Focused SOAP Note on Genitalia Assessment.
The one part of my work that I am most excited about is preventative education. A new revival within our culture of the anti-vaccination population has occurred.When faced with the question of why most do not have an answer, it really just comes down to fear and lack of specific information. I am able to provide such patients with facts through medical blogs, videos , and documents, all based on science data, as a nurse professional and with the necessary training and expertise. The patient is therefore able to make an informed decision with the provision of this knowledge that supports society as a whole.Analysis of a Focused SOAP Note on Genitalia Assessment.