Genital System Assignment Discussion

Genital System Assignment Discussion

Nurses encounter diverse patient cases in the course of their profession. In order to understand the abnormal findings in patient’s clinical assessments and analysis is significant. SOAP note case studies help in determination and documentation of abnormal results of clients. They include the subjective and objective information relevant for diagnosis and development of appropriate treatment plans. This paper examines the subjective and objective portions of a SOAP note case study involving genitalia assessment of a 21 year-old female patient, the diagnostics and differential diagnosis. Genital System Assignment Discussion

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Analysis of Subjective Data

The information provided in this section regards the history of the patient. This includes the medical history, family and social history as well as the illnesses, allergies and current medications. This portion of assessment therefore demands more information relevant to these patient aspects. For instance, providing the previous vaccination dates is critical in determining the vulnerability of the client to the prevailing healthcare risks. The portion should also tell whether the patient’s Pap smear turned positive or negative. The presence of chronic disorders in the family is worth noting also since it indicates the genetic factors influencing the current sickness.

Objective portion

The objective information portion entails an end-to-toe assessment. Here, more data about the skin color of the external genitalia, pigmentation and the type of contents observed inside the bumps. The presence, consistency and degree of bruises should also be explored. Genital System Assignment Discussion

Assessment

The objective and subjective information portions of the case study provide relevant data for clinical decision-making. However, these parts have left out important aspects of the client that could inform the clinical judgment and improve diagnosis and decision-making. Even though only a little information is left out, it is still critical in formulating the right diagnostic direction to employ to the client.

Diagnostics is an essential process of nursing assessments and investigation of symptoms and features associated with specific illnesses. They prevent medical errors from wrong diagnosis and rule out the presence of particular diseases. In his case, diagnostics will be relevant in confirming the presence of herpes simplex virus and providing test results. Results assist in the collection of important clinical information relevant for accurate diagnosis. The herpes IgG test is employed in the test for herpes simplex virus (Pahwa, Siegelman & Arya, 2015).

The diagnosis provided indicates that the client duffers from herpes simplex virus [HSV]. This follows the assessment of the specimen required. However, I reject this diagnosis because; chancres are often associated with chanchroid, syphilis and other disorders. On the contrary, herpes is characterized by painful lesions that cause tingling and itchy sores on the genitalia (Klein, 2016). According to the objective information, the client is positive for firm, round, small, painless ulcer noted on external labia. The description of these ulcers conforms more to the syphilis lesions more than those of herpes simplex virus [HSV].

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Differential diagnoses are essential in differentiating illnesses with closely related symptoms. For instance, herpes simplex virus shares similar characteristics with other sexually transmitted infections and this could undermine accurate diagnosis and development of appropriate treatment plans. The differential diagnoses for genital herpes presented in this case include syphilis, chanchroid and herpes Zoster. It is apparent from the objective and subjective portions that that syphilis conforms better to the patient information gathered. This is because; it is manifested by painless firm round lesions (Watts, Greenberg & Khachemoune, 2016). Chanchroid diagnosis is eliminated by the nature of its lesions which are soft to touch. Genital System Assignment Discussion

References

Klein, R. S. (2016). Clinical manifestations and diagnosis of herpes simplex virus type 1 infection. U: Mitty J, ur. UpToDate. UpToDate, Waltham, MA, 28, 2018.

Pahwa, A. K., Siegelman, E. S., & Arya, L. A. (2015). Physical examination of the female internal and external genitalia with and without pelvic organ prolapse: A review. Clinical Anatomy, 28(3), 305-313.

Watts, P. J., Greenberg, H. L., & Khachemoune, A. (2016). Unusual primary syphilis: Presentation of a likely case with a review of the stages of acquired syphilis, its differential diagnoses, management, and current recommendations. International journal of dermatology, 55(7), 714-728.

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Genital System Assignment Discussion