Lab Assignment: Assessing the Genitalia and Rectum
Lab Assignment: Assessing the Genitalia and Rectum
The SOAP note presents a 32-year-old female with complaints of dysuria, urinary frequency, and urgency for two days. She is sexually active and got a new sexual partner three months ago. Positive physical findings include mild suprapubic tenderness. Assessment findings are UTI and STI. The purpose of this paper is to analyze the SOAP note and describe additional information needed.
Subjective Portion
The HPI should include associated symptoms like fever or urine color changes and the severity of dysuria. It should also include the patient’s contraceptive use, including the frequency of use. The subjective part has omitted important information like the patient’s current medication, immunization history, allergies, family medical history, and social history (Podder et al., 2021). In addition, the ROS of the focused SOAP note should include all body systems and indicate pertinent positives and negatives.
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Objective Portion
The objective part is missing the patient’s height, weight, and BMI, which are essential in determining the patient’s nutritional status. In addition, it should have exam findings from the general assessment, which includes the patient’s appearance, hygiene, mood, speech, gait, and mannerism (Podder et al., 2021). It should also have cardiovascular and respiratory exam findings, which are mandatory for focused exams.
Assessment
The assessment finding of UTI is supported by subjective findings of dysuria, urinary urgency, frequency, and flank pain. It is also supported by physical exam findings of suprapubic tenderness on palpation (Kornfält Isberg et al., 2021). STI is supported by findings of dysuria, pelvic pain, and suprapubic tenderness on palpation.
Physical Exams and Diagnostic Tests
Appropriate diagnostic tests include a complete blood count to assess for infection and a urine culture to diagnose UTI. Urine culture is usually used to investigate dysuria and is the criterion standard for diagnosing UTI (Kornfält Isberg et al., 2021). Besides, a vaginal culture can be recommended to rule out STIs like N. gonorrhoeae and Chlamydia trachomatis. A vaginal and urethral smear using a wet-mount preparation can rule out Trichomonas vaginalis, which presents with dysuria and flank pain.
Differential Diagnoses
UTI is an appropriate diagnosis for this patient based on positive findings of dysuria, flank pain, urinary frequency, and urgency, which are the typical symptoms of UTI (Kornfält Isberg et al., 2021). Thus, I would accept the diagnosis. However, I would reject STI since the diagnosis is not specific to the type of STI. The conditions that can be regarded as differential diagnoses include:
Urinary Tract Infection (UTI): The clinical manifestations of UTI include dysuria, urinary urgency, frequency, a feeling of bladder fullness, lower abdominal discomfort, suprapubic tenderness, flank pain, bloody urine, malaise, and fever (Kornfält Isberg et al., 2021). The patient has positive symptoms of dysuria, urinary frequency, urgency, flank pain, and suprapubic tenderness, making UTI a presumptive diagnosis.
Cystitis: This is a non-infectious inflammation of the bladder that manifests with dysuria, suprapubic, pelvic, and abdominal pain, urinary frequency, urgency, and incontinence (Frazier & Huppmann, 2020). Cystitis is a differential based on the patient’s findings of dysuria, urinary frequency, urgency, flank pain, and suprapubic tenderness.
Pelvic inflammatory disease (PID): PID presents with lower abdominal pain, cervical discharge, fever, and abnormal uterine bleeding (Curry et al., 2019). This is a possible diagnosis based on the symptoms of flank pain and suprapubic tenderness.
Conclusion
The subjective part should have associated symptoms, the severity of dysuria, immunization status, family medical history, social history, and ROS of all body systems. The objective should include a general assessment, cardiovascular, and respiratory findings. Urine culture, CBC, vaginal culture, and vaginal smear can be ordered to confirm or rule out UTI and STIs. The possible diagnoses are UTI, cystitis, and PID.
References
Curry, A., Williams, T., & Penny, M. L. (2019). Pelvic Inflammatory Disease: Diagnosis, Management, and Prevention. American Family Physician, 100(6), 357–364.
Frazier, R. L., & Huppmann, A. R. (2020). Educational Case: Acute Cystitis. Academic pathology, 7, 2374289520951923. https://doi.org/10.1177/2374289520951923
Kornfält Isberg, H., Hedin, K., Melander, E., Mölstad, S., & Beckman, A. (2021). Uncomplicated urinary tract infection in primary health care: presentation and clinical outcome. Infectious Diseases, 53(2), 94-101. https://doi.org/10.1080/23744235.2020.1834138
Podder, V., Lew, V., & Ghassemzadeh, S. (2021). SOAP notes. In StatPearls [Internet]. StatPearls Publishing.
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