The fact that she does not use tobacco, but uses etoh, a particular alcohol type that comprised of two molecules of carbon,is important to guide the doctor in making an effective prescription. This is because some of the medications tend to be ineffective when combined with any alcohol rendering them powerless in the treatment process. In this case, the patient seems to have provided all the relevant medical history information which includes gynaecological background, family history, sexual history, general and specific risk factors, and surgical history (LeBlond, Brown,&DeGowin, 2014). However, the patient can also be asked whether the bumps have been changing in terms of size and whether they are affecting the patient’s sexual life. Critical information that should have been included in this assessment is whether the patient has used contraceptives and what types as the bumps could be as a result of these contraceptives.
WEEK 10 ANALYZE SOAP NOTE 4 Objective Portion In this section, the assessment began with the key vital signs to ensure whetherthe patient was functioning normally (Seidel et al., 2011). Based on the findings of the patient has normal ranges for the basic vitals including the body temperature, blood pressure and respiratory rate. However, the patient seems to be overweight as indicated by her BMI whichis 33.13 for 169lb in weight and 5 ft.1 in tall. Despite being overweight, the client’s heart has a regular rate and rhythm without murmurs in the heart. This information is important to the doctors as it enables them to identify potential treatment plans that will not affect the patient’s vital signs in a significant way. The lungs have been tested using the coronary computed tomography angiogram (CTA) to detect any possible blockages in the heart’s arteries. This method is non-invasive as it uses CT technology and an intravenous contrast material in form of a dye to get a high-resolution 3D picture of a mobile heart in action and its vessels. This information shows that the overweight condition of the patient has not affected the patient’s heart and lungs. An observation of the client’s genital area shows that there are normal conditions in terms of distribution ofhair patterns and no abnormal discharge. There is the presence of a healed episiotomy scar which cannot be attributed to have caused the bumps. However, the pink virginal mucosa can also indicate an infection in the urethra. Also, it is important to understand that the patient has small and painless ulcers on the external labia. This indicated that the bumps were unrelated to the ulcer which could have been caused by sexual activities rather than an infection.
WEEK 10 ANALYZE SOAP NOTE 5 The abdominal conditions tested were normal where the Murphy’s and McBurney tests were negative (Sullivan, 2012). This information was important to eliminate possible digestive conditions that could have been associated with causing the lumps. Afterwards, a
- Summer '15
- Human Sexuality, Sexual intercourse, Human sexual behavior, analyze soap