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ASSESSING THE GENITALIA AND RECTUM SOAP Note Analysis: Assessing the Genitalia and Rectum Danielle Black-Smith NURS 6512: Advanced Health Assessment Walden University May 11 th , 2019 1
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ASSESSING THE GENITALIA AND RECTUM GENITALIA ASSESSMENT Subjective: 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 over 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. PMH: Asthma Medications: Symbicort 160/4.5mcg Allergies: NKDA 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) Objective: 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 with a healed episiotomy scar present. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, neg McBurney Diagnostics: HSV specimen obtained Assessment: Chancre
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  • Fall '13
  • Human Sexuality, Sexual intercourse, Human sexual behavior, Sexually transmitted diseases and infections, Rectum

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