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Case Study for Evaluation This is all the in the SOAP note GENITALIA ASSESSMENT Subjective: CC: I have bumps on

Case Study for Evaluation (This is all the in the SOAP note)
GENITALIA ASSESSMENT
Subjective:
CC: “I have bumps on my bottom that I want to have checked
out.”
HPI: AB, a 21-year-old WF college student reports to your
clinic with external bumps on her genital area. She states the bumps are
painless and feel rough. She states she is sexually active and has had
more than one partner during the past year. Her initial sexual contact
occurred at age 18. She reports no abnormal vaginal discharge. She is
unsure how long the bumps have been there but noticed them about a week
ago. Her last Pap smear exam was 3 years ago, and
no dysplasia was found; the exam results were normal. She
reports one sexually transmitted infection (chlamydia) about 2 years ago.
She completed the treatment for chlamydia as prescribed.
PMH: Asthma
Medications: Symbicort 160/4.5mcg
Allergies: NKDA
FH: No hx of breast or cervical cancer,
Father hx HTN, Mother hx HTN, GERD
Social: Denies tobacco use; occasional etoh, married, 3
children (1 girl, 2 boys)
Objective:
VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Genital: Normal female hair pattern distribution; no masses
or swelling. Urethral meatus intact
without erythema or discharge. Perineum intact. Vaginal mucosa
pink and moist with rugae present, pos for firm,
round, small, painless ulcer noted on external labia.
Abd: soft, normoactive bowel sounds, neg rebound,
neg murphy’s, negMcBurney
Diagnostics: HSV specimen obtained
Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.
Analyze the subjective portion of the note. List
additional information that should be included in the documentation.
Analyze the objective portion of the note. List
additional information that should be included in the documentation.
Is the assessment supported by the subjective and
objective information? Why or why not?
Would diagnostics be appropriate for this case, and how
would the results be used to make a diagnosis?
Would you reject/accept the current diagnosis? Why or
why not? Identify three possible conditions that may be considered as a
differential diagnosis for this patient. Explain your reasoning using at
least three different references from current evidence-based literature.

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