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Nurs 6512N-Week 10Assessing the Genitalia and RectumAlleda GlasnerMay 3, 2019
Week 10 Analyze SOAP NoteThe SOAP not case study presents a twenty-one-year-old female patient that complains of external bumps on her genital area that she noticed a week ago. She states the bumps are painless and rough to touch. She is also noticing vaginal discharge. Once in the consultation room, the practitioner learns that the patient is sexually active since the age of eighteen and has more than one partner. She reports having a pap smear three years ago with normal results. She also tells the practitioner that she was diagnosed with chlamydia approximately two years ago and completed the treatment as prescribed. Subjective DataCollecting subjective data from the patient is crucial because this is the starting point for the nurse practitioner. This data gives the practitioner the background of the reason of going to the clinic. Subjective data includes the patient’s symptoms, feelings, perceptions, and concerns[ CITATION Bri17 \l 1033 ]. This patient gave some helpful information. Knowing that the bumps are painless with rough edges could eliminate some diagnosis. Thereis much information that could be asked about the bumps on this patient. One questions couldbe, “does anything make the bumps itch or burn?” Some other questions could be, “have you ever noticed bumps like this in the past,” “are the bumps only on your bottom or are they on other places of your body,” and “do any of your partners have these same symptoms or been recently diagnosed with an STD?” Some additional subjective information for this patient could include urinary symptoms. The practitioner should ask about burning on urination, urinary urgency, and urinary frequency. Knowing more about the sexual history of this patientis imperative. Although she told the nurse practitioner about her sex partners, knowing the last time of intercourse and if it was painful could lead the provider to the correct diagnosis.
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Sexual intercourse, Human sexual behavior, Molluscum contagiosum