Running Head: ASSESSING THE GENITALIA AND RECTUM1Health Assessment SOAP Note: Assessing the Genitalia and Rectum
ASSESSING THE GENITALIA AND RECTUM2Analysis ofthe subjective portionOne of the first things to consider is whether there are bumps anywhere else on the body or only the genitalia and whether the bumps are painful and rough.Testing such as the digital rectal examination is necessary to improve health outcomes, but there is a need for best practice to achieve this (Sabbagh et al., 2014). The bumps may be present at all the times, or come and go. If there is anything that appears to aggravate the bumps like soap or clothing then this should be noted, it is also necessary to assess whether there are things that make the bumps disappearPast Medical History (PMH): Asthma, ChlamydiaAny past history of other STIsAny skin conditionsAge of Asthma diagnosis andcomplications if anyMedication previously prescribed for ChlamydiaPast Surgical History (PSH): Such as c-sections and femalesurgeries,Medications:Are there acute medicationsSexual/Reproductive HistorySexual orientation History of sexually transmitted infectionsInfertilityType of contraception usedAbortions Number of children
ASSESSING THE GENITALIA AND RECTUM3Analysisofthe objective portionThe patient has no other major healthproblemsheis well spokengroomed, dressed,clean and makes eye contact. Assess the throat for any infections, lesions and cold sores. For the neck, there is focus on the range of motion, cervical and clavicular lymph nodes, position, thyroid examination and mobility of the trachea(Dains, Baumann & Scheibel, 2016).For the genital/rectal, thereis an inspectionof the perineum for nits, lesions areas of swelling or tenderness ovarian enlargement, masses,hair distribution, and tenderness. She had a Pap smear threeyears ago and was toldit was normal, but there has been no information on the mammography.Assessmentand diagnosisSyphilisThetransmission of some bacterial infections likesyphilis requires human-to-human contact, and Chlamydia, which may be contractedas an STI, mayspread to the child duringchildbirth.Thesubjective and objective data supportthe diagnosis, but focus on thefalse-positive serologic test for syphilis isnecessaryto make accurateassessments. Pelvic examination is also carried out to identify and rule out diseases and infections (Westhoff, Jones &Guiahi, 2011).Herpes Simplex Type-2Herpes simplex virus-2 (HSV-2) mainly infects the genitalia, and the viruses at times affect the skin and the oral cavity or the central nervous system. There are recurrent genital symptoms, and oneof the man challenges is preventing recurrences of the infections. Herpes is highly contagious, and there are no indications that the patienthas suffered recurrent infections.
ASSESSING THE GENITALIA AND RECTUM4The subjective data for herpes simplex is “tenderness, pain, paresthesia, or mild burning at the infected site before the onsetof the lesions” (Ballet al., 2015).Herpes Progenitalis with asymptomatic ChlamydiaWhile the diagnosis is unlike, the patientas a history of Chlamydia and her sexual history influences the risk of more infections. Chlamydial genital infectionsmay beasymptomatic,andlaboratory evaluation is necessary to diagnosethe diseaseand rule out thediseases and differ infections.Acute Contact DermatitisReactivedermatitis and contact dermatitis are skin disorders that affect the genital tract,andsuch disorders are sexually transmitted. Acute contact dermatitis causes inflammation and is mostlycharacterizedby lesions. Diagnostics will help rule out acute contact dermatitis and other dermatologic disorder.Insect BitesInsect bites are unlikely to be the main cause of the bump. However,determining her activities beforethe bump appearing such as being in places with many insects is useful to determine the risks. Insect bites can cause various skin disorders and infection of the dermis and subcutaneous tissue.PlanAssessing the skin and documenting this is the first step to determine the interventions that are most appropriate, besides this intervention, there are laboratory tests to determine the patient health status. The medications and treatment m depend onwhathas been identifiedand what has been ruled out. Theexpected outcome is that the patient will not experience a recurrenceof Chlamydia infections or pain and the bump will be dealtwith. Theplanning and
ASSESSING THE GENITALIA AND RECTUM5implementation focuson administeringthe medication asrequired, emphasizing theneed for regular checkups and discussing concerns about the diagnosis.ReferencesBall, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination(8th ed.). St. Louis, MO: Elsevier Mosby.Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care(5th ed.). St. Louis, MO: Elsevier Mosby.Sabbagh, C., Mauvis, F., Vecten, A., Ainseba, N., Cosse, C., Diouf, M., &Regimbeau, J. M. (2014). What is the best position for analyzing the lower and middle rectum and sphincter function in a digital rectal examination? A randomized, controlled study in men. Digestive and Liver Disease, 46(12), 1082–1085.doi:10.1016/j.dld.2014.08.045Westhoff, C. L., Jones, H. E., &Guiahi, M. (2011). Do new guidelines and technology make the routine pelvic examination obsolete? Journal of Women’s Health, 20(1), 5–10
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