not fully support all the Ps so did not include all the necessary sexual health

Not fully support all the ps so did not include all

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not fully support all the P’s so did not include all the necessary sexual health needed to assess the pasts STD risk factors. Patients urinary output was never addressed. Many STDs cause increased pain upon urination, discoloration, puss or increased smell of urine. Missing Objective Information When assessing a female patient that comes into the clinic with genitalia complication is it important to not only inspect the labia and the vaginal and anal areas but to do internal inspections as well. Women whom are sexually active should have internal inspections of the uterus to assess for internal masses, pain upon palpation, vaginal discharge, and inflammation of fallopian tubes and ovaries. This inspection was not done in the SOAP note and it also neglected to provide a detailed rectal exam. Missing Diagnostic Testing This patient should have a full pelvic exam due including biopsies and pap smear sent to the lab to rule out a number of sexually transmitted diseases. That should also have DNA testing
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GENITALIA AND RECTUM ASSESSMENT 6 done to find out if she does in face have syphilis, chlamydia, or herpes. HIV blood test should also be sent. A urine culture along with an HCG test should be sent because of the patient does have an STD there is a 50% chance that she can transmit it to her unborn child which increases the infant’s risk of mortality (Dains, Baumann, & Scheibal., 2016). An acetic acid test should be done to quickly rule out genital warts and an underlying reason of HPV. Women whom are sexually active and neglect to use protection are at an extreme risk of contracting HPV which eventually turns into uterine and cervical cancer. Three Differential Diagnoses 1. Genital Warts: In some cases, genital warts can be associated with an HPV infection because they are what manifest late into the infection process and are known as condylomata acuminate (Kent, B.M., 2017). The warts can be one lesion or can be clustered into many lesions. They are characterized as soft and painless and patients whom do not practice safe sex are at the highest risk for contracting the disease. 2. Herpes Simplex Virus: One of the most common sexually transmitted diseases which can be seen as sores on the genital area (Hover, & Bertke., 2017). Patients that are at the greatest risk of acquiring the infection are those that are uneducated, frequently have unprotected sex with multiple partners and are of lower socioeconomic level. Another risk factor is if both spouses are not assessed when one of the spouses is diagnosed with the virus. Usually patient presents with burning upon urination and or vaginal itching and discharge.
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  • Summer '15
  • Human Sexuality, Sexual intercourse, Human sexual behavior, Rectum

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