Clinicians' Duty: Analyzing SOAP Notes to Capture Patient Info - Essay Sample

Introduction

Clinicians have a sole duty to analyze both the SOAP note of their clients as the standard method designed to provide patient information. When analyzing the objective and the subjective portions of a SOAP note, certain patient information such as medical history, admission, and drug prescription are captured electronically (Ricord & Bell, 2018). The subjective part takes into consideration the orally expressed information about the patient's symptoms while the objective part considers all the measurable factors of the patient's symptoms such as what is seen, heard, felt or smelled. In this paper, therefore, we seek to analyze both the subjective as well as the objective parts as provided by the AB, a teenage WF college student during the patient cross-examination.

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Subjective Portion

On the onset, the teenage WF College student is experiencing painless bump though he is not sure the longer she has had the bumps at the bottom of her genitals. The patient is experiencing the bumps on the bottom of her genital area, however, the character of the bump is painless though it feels rough. Moreover, the patient reports no abnormal vaginal discharge that is to say there is no signs of dysplasia were noticed; and the results were normal as some of the alleviating factors. Either, there are no signs of radiation and there are no other symptoms associated with the painless bump. However, she reports chlamydia, a one sexually transmitted infection which she says she had contracted two years ago which she has sought the medical assistance from a clinical officer.

Objective Portion

She has normal female hair pattern distribution at the genitals with no masses or swelling. It is three years ago when she had her last Pap smear examination and based on the results there was no dysplasia. From the results of the diagnostic tests, she had her urethral meatus undamaged and therefore had no discharge. Perineum was also undamaged; however she had her episiotomy scar fully healed. She also had vaginal mucosa moist and pink with rugae showing in her pos for firm, round, small, painless ulcer.

Assessment

A painless, indurated bump on the bottom aspect of the genital is an indication of perforating chancre. Perforating chancre heals within 1-2 weeks of treatment with penicillin without scarring. This assessment is supported by the subjective because of the painless bump that the patient had been experiencing on the bottom side of the genitals.

Diagnostic

The diagnosis of Chancroid will present a patient with genital ulcer syndrome. The disease is most prevalent with a patient who is sexually active having had several sexual partners in the past. However, the patient will to a greater extent experience pus from their genital ulcers, a symptom that is highly associated with chancroid (Roett, Mayor & Uduhiri, 2012).

Conclusion

Consequently, I would accept the current diagnosis because of the presence of a painless, indurated bump on the bottom aspect of the genital as an indication of perforating chancre. One of the possible condition which may be taken into consideration as a variance diagnosis for the patient is lymphogranuloma venereum, a disease that has a history of indurated genital ulceration (Singhrao, Higham & French, 2011). Another possible condition may be syphilis, a disease that is common with chancres perforation of the genitalia (Gellhokn & Ehhenfest, 2016). The last though the most unlikely possible condition is HIV infection because it is presumed to be responsible for this destructive sequela.

References

Gellhokn, G., & Ehhenfest, H. (2016). Syphilis of the Internal Genital Organs in the Female. Transactions of the American Gynecological Society, 41, 129.

Ricord, P., & Bell, G. (2018). Practical Observations on Chancre. Edinburgh Medical and surgical journal, 50(136), 146.

Roett, M. A., Mayor, M. T., & Uduhiri, K. A. (2012). Diagnosis and management of genital ulcers. American family physician, 85(3).

Singhrao, T., Higham, E., & French, P. (2011). Lymphogranuloma venereum presenting as perianal ulceration: an emerging clinical presentation?. Sexually transmitted infections, 87(2), 123-124.