This week you will look at
- Evaluate abnormal findings on the genitalia and rectum
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the breasts, genitalia, prostate, and rectum
This week you will have an analysis of a SOAP note. It is important to remember that this is not to be in SOAP note format. This should be a narrative paper.
Here is the case that you will base this on:
GENITALIA ASSESSMENT
Subjective:
- CC: dysuria and urinary frequency
- HPI: RG is a 30 year old female with increase urinary frequency and dysuria that began 3 days ago. Pain is intermittent and described a burning only in urination, but c/o flank pain since last night. Reports intermittent chills and fever. Used Tylenol for pain with no relief. She rates her pain 6/10 on urination. Reports a similar episode 3 years ago.
- PMH:UTI 3 years ago
- PSHx:Hysterectomy at 25 years
- Medication:Tylenol 1000 mg PO every 6 hours for pain
- FHx:Mother breast cancer ( alive) Father hypertension (alive)
- Social:Single, no tobacco , works as a bartender, positive for ETOH
- Allergies:PCN and Sulfa
- LMP:N/A
Review of Symptoms:
- General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
- Abdominal: Denies nausea and vomiting. No appetite
Objective:
- VS: Temp 100.9; BP: 136/80; RR 18; HT 6’.0”; WT 135lbs
- Abdominal: Bowel sounds present x 4. Palpation pain in both lower quadrants. CVA tenderness
- Diagnostics: Urine specimen collected, STD testing
Assessment:
- UTI
- STD
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Genitalia Assessment SOAP Note Analysis:
The patient, RG, a 30-year-old female, presented with complaints of dysuria and increased urinary frequency. She reported that these symptoms had started three days ago. The pain was intermittent, described as a burning sensation during urination, and she also complained of flank pain since the previous night. Additionally, the patient mentioned experiencing intermittent chills and fever. She had used Tylenol for pain relief but found no relief. She rated her pain as 6/10 during urination. She also reported a similar episode three years ago and had a history of a UTI at that time.
RG’s past medical history included a hysterectomy at the age of 25, and her medication history included Tylenol 1000 mg orally every 6 hours for pain. Family history noted her mother having breast cancer, and her father having hypertension. Socially, RG was single, a non-tobacco user, worked as a bartender, and reported positive alcohol use. Her allergies included penicillin (PCN) and sulfa. Her last menstrual period (LMP) was not applicable.
Upon review of symptoms, RG denied any weight change, but she did report sleeping difficulties due to flank pain. She also mentioned feeling warm but denied nausea, vomiting, and a loss of appetite.
Objective findings revealed the following:
- Vital signs: Temperature was 100.9°F, blood pressure was 136/80 mm Hg, respiratory rate was 18 breaths per minute, height was 6’0″, and weight was 135 lbs.
- Abdominal examination: Bowel sounds were present and active in all four quadrants. However, palpation elicited pain in both lower quadrants, and there was costovertebral angle (CVA) tenderness.
- Diagnostics: A urine specimen was collected, and STD testing was initiated.
Based on the subjective and objective data, the assessment included a preliminary diagnosis of a urinary tract infection (UTI) and the consideration of a sexually transmitted disease (STD).
The plan section was not provided, but it would typically include the recommended course of treatment, further diagnostic tests if necessary, and instructions for the patient.
In summary, the patient RG presented with urinary symptoms suggestive of a UTI. The medical history, physical examination, and diagnostic tests will aid in confirming the diagnosis and guiding the appropriate treatment plan, which should address the UTI and consider the possibility of an STD.