SOAP Note on Genitalia and Rectum Assessment

1 Genitalia and Rectum Assessment SOAP Note on Genitalia Assessment Patient Information: B.T. 21-years-old, Female, Subjective CC. “I am here because I want the bumps that have developed on my bottoms checked out.”

HPI: The client is a 21-year-old female in the clinic complaining of bumps on her bottom. The client clarified that she noticed the bumps a week ago but was uncertain when they first occurred.

Location: The anal-genital region Onset: She noticed the bumps a week ago Character: rough and non-painful bumps Associated signs and symptoms: None Timing: N/A Exacerbating/relieving factors: none Severity: painless

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2 Medications: The client is currently on Symbicort 160/4.5 mcg for asthma Allergies: the client is allergic to a cold-weather that triggers asthmatic reactions PMH: The client has asthma and was diagnosed with chlamydia infection two years ago.

Soc Hx: The client is a student and does not engage in alcoholism and cigarette smoking Fam Hx: Father and mother have no severe chronic conditions.

PMH: the client had her Pap test three years ago, and the results did not identify any possible disorder

3 ROS: GENERAL: No fever, excessive night sweats, decreased appetite, and chills HEENT: Head: No headaches, migraine, or head injuries.

Eyes: No visual changes, No loss of visual acuity, no redness, inflammation, and tearing of the eyes.

Ears, Nose, Throat: No congestion and excessive mucus. No sore throat and oral thrush SKIN: The client has round bumps on the genital area CARDIOVASCULAR: No chest pain, No palpitations RESPIRATORY: No dry coughs, no wheezes, no shortness of breath.

GASTROINTESTINAL: No gastrointestinal symptoms like bloating, constipation, pain, vomiting, and diarrhea.

GENITOURINARY: No pain and burning sensation, incontinence, and hematuria.

NEUROLOGICAL: No disorientation and paralysis MUSCULOSKELETAL: No joint pain, stiffness, inflammation, and decreased movement HEMATOLOGIC: Denies nose bleeding, easy bruising, and anemia LYMPHATICS: Ni signs of tonsillitis and inflamed lymph nodes PSYCHIATRIC: No depression and anxiety ENDOCRINOLOGIC: No excessive hunger and thirst, No intolerance to heat and cold.

ALLERGIES: The client is asthmatic Objective Vital signs: Temp 98.6; Pulse rate 92; 02 99%, RR 16; height 5’10”, Weight 169lbs; BMI 24.20; Blood Pressure 120/86

4 General — The client is alert and does not display possible distress or anxiety HEENT Head: The clients head is normocephalic, with no scar or fresh traumatic blows Eyes: No pupil infection was noticed. The sclera is white, and the conjunctiva is pink.

Ears: No infections of the pupils, pink conjunctiva, and white sclera were observed Nose: no congestion, turbinate clear, nostrils open Neck: Neck flexibility not affected. No lymphadenopathy Mouth/Throat: No erythematous throat Skin: small round bumps were observed along with the genital and anal areas Cardiovascular- S1&S2 present, no murmurs and gallops, no palpitations Gastrointestinal — No abdominal obesity, scars, injuries, or distension observed. The abdomen is soft with no rebound. Normoactive bowel sounds were heard in all quadrants.

Pulmonary— No shortness of breath, the chest is symmetrical, no sputum production.

Musculoskeletal: all extremities have a normal range of motion, without stiffness and inflammation Lab test: HSV Culture Assessment Chancre (A57) The patient has small painless bumps around the anal and genital region, which resemble a chancre. These bumps occur within a month of exposure to Treponema pallidum associated with syphilis infection (Thomas, Kumar, Balaji & Devaraj, 2016). The client’s risk of contracting an STI is high, considering she has multiple sexual partners.

5 Differential Diagnoses Herpes simplex (B00.82) – Herpes symptoms include blisters on the genital areas, pain and itching around the anogenital region, and flu-like symptoms (Bieber, Sanfilippo, Horowitz & Shafi, 2015).

Behçet's disease - (M35. 2) – genital ulcers and acne-like spots are the main symptoms (). Other symptoms include vision disorders, persistent headaches, and joint pain.

Psoriasis - (L40.9) – Itchy burning sores and thick red patches on the skin are the typical symptoms of psoriasis (Wein et al. 2015).

Plan Additional lab tests - A Pap test - Urine test - Rapid tests- gonorrhea and chlamydia.

Treatment The client was given a single dose of Azithromycin 1 gm The client to maintain hygiene in the anogenital area and avoid dirty clothes Use mild soap and warm water to avoid irritating the small bumps Education - Patient education was focused on the reduction of sexual partners Follow-up plan – The next visit was scheduled after ten days Self-Assessment & Clinical Guidelines The client was open and provided vital information concerning her sexual life. The relevant lab tests were, and the results confirmed a Chancre. The clinician prescribed the client a single dose

6 of azithromycin. HSV culture is usually conducted when the client has bumps and rashes in the genital area that typify a viral infection (Thomas, Kumar, Balaji, & Devaraj, 2016). A urine analysis is also necessary since the client might be having a bacterial infection such as UTI.

7 References

Thomas, J., Kumar, P., Balaji, S. R., & Devaraj, D. K. (2016). Genital dermatoses. The Health Sciences Publishers Bieber, E. J., Sanfilippo, J. S., Horowitz, I. R., & Shafi, M. I. (Eds.). (2015). Clinical gynecology. Cambridge University Press.

Wein, A. J., Kavoussi, L. R., Partin, A. W., Peters, C., & Campbell, M. F. (2015). CampbellWalsh urology. Elsevier