SOAP Assessment for Female Genitalia

SOAP Assessment for Female Genitalia

The assessment of the genital and the lower abdominal parts of the body may be a challenge in some cases especially in the situation where the patient is not free to discuss their condition freely. The process of assessment starts with the subjective assessment so as to get the general overview of the patient condition (Muliira, Seshan, & Ramasubramaniam, 2013). The objective assessment would then follow thus making it possible to develop suitable features for the control of the patient condition. This paper discusses the subjective and the objective assessment for a female patient presenting with genital bumps. The differential diagnosis for the possible conditions are also provided.

Additional Subjective Assessment

Subjective assessment is also important in guiding the healthcare provider on the possible objective tests to carry out. In the presented case study, various additional subjective information could be obtained to further attain the effective diagnosis for the presenting condition (Muliira, Seshan, & Ramasubramaniam, 2013). One of the additional information is to know whether the current sexual partner has complained of any abnormal genital experiences lately. It could also be important to know whether the current sexual partner have history of sexually transmitted conditions. It would also be important to know the last time they have head unprotected sex. This would inform to understand whether the patient may have been exposed to a sexually transmitted condition.

The other subjective assessment would be to find out whether the patient have had a new underwear in the past one month. It is also important to understand where the patient may have used a new product such as bathing soap lotion or cream in the last one month. This would guide to understand whether the patient may have been exposed to irritants. The should also be assessed to find out whether she has ever had a surgical procedure at her genital area.

Objective Assessment

The objective assessment provides a more differentiated outcome that may help in the diagnosis of the condition. Considering that the condition causing the main complaint is more focused around the vaginal area, the objective assessment should therefore be around this area of focus (Davis, et al. 2020). One of the objective assessment that would be additionally carried out would be to have a urinalysis to rule in or out the possibility of bacterial and viral infections. The other objective assessment that should be considered is to assess for varicosities. This would help to determine the possible diagnosis of venous disease that may be identified in the pelvis. Considering that she is a mother of two, it may be important to determine the possibility of vaginal atrophy assessment. The would help to rule out the possibility of such conditions. Palpation may also help to establish whether there are scars at the vaginal area either frim previous surgeries or also from the possibility of any other physical injuries. These may determine the presence of such conditions like episiotomy condition.  An assessment of the cervix may also help toe established whether the patient cervix is regular or irregular (Davis, et al. 2020). It would also be important to determine the consistency of the harness and the softness of the cervix walls. The assessment may also be extended to the uterus to find out the position and the surface characteristics by palpating. This would also help to rule out any possible internal extension of the systems observed at the external.

Whether the Assessment is Supported by the Subjective and Objective Information

The assessment that was carried out could be supported by the objective and the subjective information obtained from the assessment of the patient condition. The assessment cuts across most of the crucial information that may be required for the come up with a diagnosis for the condition (Davis, et al. 2020). The fact that the patient does not experience any discharge may rule out the possibility of the patient having any sexually transmitted health condition. Taking the HSV sample from the bumps will help to establish the type of virus that the patient could be having.

Possible Differential Diagnostic Conditions

One of the differential diagnosis for this patient condition is Herpes Simplex Virus. Considering the growth of bumps at the genital area, this could be an indication that the patient may be HVS. HVS is known to be carried in the body for a long period of time before the symptoms occur, thus this cannot be ruled out until the lab test outcome is obtained (Wagenlehner, et al. 2016). The other differential diagnosis for the condition is the genital warts. This could be considered form the perspective that the patient is sexually active and reports having more than one sexual partner in the last one year. This predisposes her to human papillomavirus which is more likely for sexually active individuals. The third diagnosis for the condition would be to have a suitable feature of concern that would be associated with the control of the patient condition (Wagenlehner, et al. 2016). The other differential diagnosis for the condition is contact dermatitis condition. This condition occurs when the patient encounters an allergen. The patient may develop blisters that may be specifically around the genital area.

Summary

The assessment for genital health conditions may be challenging considering that the patient may be shy to share their experience. Patients may also be uncomfortable with the assessment process and thus may lead to unreliable outcome. It is always important therefore to maintain patient autonomy while also seeking to win the confidence of the patient. This would improve the level of accuracy for the diagnosis of the underlying condition. Subjective and objective data contributes effectively to the accuracy of the diagnosis.

References

Davis, A. L., Pecaric, M., Pusic, M. V., Smith, T., Shouldice, M., Brown, J., … & Boutis, K. (2020). Deliberate practice as an educational method for learning to interpret the prepubescent female genital examination. Child Abuse & Neglect, 101, 104379.

Muliira, R. S., Seshan, V., & Ramasubramaniam, S. (2013). Improving vaginal examinations performed by midwives. Sultan Qaboos University Medical Journal, 13(3), 442.

Wagenlehner, F. M., Brockmeyer, N. H., Discher, T., Friese, K., & Wichelhaus, T. A. (2016). The presentation, diagnosis, and treatment of sexually transmitted infections. Deutsches Ärzteblatt International, 113(1-2), 11.