SOAP Assessment For Female Genitalia

SOAP Assessment for Female Genitalia  The assessment of the genital and the lower abdominal parts of the body may be a challenge in some cases, especially in situations where the patient is not free to discuss their condition freely. The process of assessment starts with a subjective assessment so as to get a general overview of the patient’s condition (Muliira, Seshan, & Ramasubramaniam, 2013). The objective assessment would then follow thus making it possible to develop suitable features for the control of the patient’s condition. This paper discusses the subjective and objective assessment of a female patient presenting with genital bumps.

The differential diagnosis for the possible conditions is also provided.  Additional Subjective Assessment Subjective assessment is also important in guiding the healthcare provider on the possible objective tests to carry out. In the presented case study, various additional subjective information could be obtained to further attain an effective diagnosis for the presenting condition (Muliira, Seshan, & Ramasubramaniam, 2013). One of the additional information is to know whether the current sexual partner has complained of any abnormal genital experiences lately. It could also be important to know whether the current sexual partner has a history of sexually transmitted conditions. It would also be important to know the last time they have had unprotected sex. This would inform to understand whether the patient may have been exposed to a sexually transmitted condition.   The other subjective assessment would be to find out whether the patient has had new underwear in the past month. It is also important to understand where the patient may have used a new product such as bathing soap lotion or cream in the last month. This would guide to understand whether the patient may have been exposed to irritants. They should also be assessed to find out whether she has ever had a surgical procedure on her genital area. 

Objective Assessment The objective assessment provides a more differentiated outcome that may help in the diagnosis of the condition. Considering that the condition causing the main complaint is more focused around the vaginal area, the objective assessment should therefore be around this area of focus (Davis, et al. 2020). One of the objective assessments that would be additionally carried out would be to have a urinalysis to rule in or out the possibility of bacterial and viral infections. The other objective assessment that should be considered is to assess for varicosities. This would help to determine the possible diagnosis of venous disease that may be identified in the pelvis. Considering that she is a mother of two, it may be important to determine the possibility of vaginal atrophy assessment. The would help to rule out the possibility of such conditions. Palpation may also help to establish whether there are scars in the vaginal area either from previous surgeries or also from the possibility of any other physical injuries. These may determine the presence of such conditions as episiotomy conditions.

 An assessment of the cervix may also help to establish whether the patient’s cervix is regular or irregular (Davis, et al. 2020). It would also be important to determine the consistency of the harness and the softness of the cervix walls. The assessment may also be extended to the uterus to find out the position and the surface characteristics by palpating. This would also help to rule out any possible internal extension of the systems observed at the external.  Whether the Assessment is Supported by the Subjective and Objective Information The assessment that was carried out could be supported by the objective and the subjective information obtained from the assessment of the patient’s condition. The assessment cuts across most of the crucial information that may be required the come up with a diagnosis for the condition (Davis, et al. 2020). The fact that the patient does not experience any discharge may rule out the possibility of the patient having any sexually transmitted health condition. Taking the HSV sample from the bumps will help to establish the type of virus that the patient could be having. 

Possible Differential Diagnostic Conditions One of the differential diagnoses for this patient’s condition is the Herpes Simplex Virus. Considering the growth of bumps in the genital area, this could be an indication that the patient may be HVS. HVS is known to be carried in the body for a long period of time before the symptoms occur, thus this cannot be ruled out until the lab test outcome is obtained (Wagenlehner, et al. 2016). The other differential diagnosis for the condition is genital warts. This could be considered from the perspective that the patient is sexually active and reports having more than one sexual partner in the last year. This predisposes her to human papillomavirus which is more likely for sexually active individuals. The third diagnosis for the condition would be to have a suitable feature of concern that would be associated with the control of the patient’s condition (Wagenlehner, et al. 2016). The other differential diagnosis for the condition is contact dermatitis condition. This condition occurs when the patient encounters an allergen.

The patient may develop blisters that may be specifically around the genital area.  Summary The assessment for genital health conditions may be challenging considering that the patient may be shy to share their experience. Patients may also be uncomfortable with the assessment process and thus may lead to unreliable outcomes. It is always important therefore to maintain patient autonomy while also seeking to win the confidence of the patient. This would improve the level of accuracy for the diagnosis of the underlying condition. Subjective and objective data contribute effectively to the accuracy of the diagnosis. 

References Davis, A. L., Paris, M., Pusic, M. V., Smith, T., Shouldice, M., Brown, J., … & Boutis, K. (2020). Deliberate practice is an educational method for learning to interpret the prepubescent female genital examination. Child Abuse & Neglect, 101, 104379. Muliira, R. S., Seshan, V., & Ramasubramaniam, S. (2013). Improving vaginal examinations performed by midwives. Sultan Qaboos University Medical Journal, 13(3), 442. Wagenlehner, F. M., Brockmeyer, N. H., Discher, T., Friese, K., & Wichelhaus, T. A. (2016). The presentation, diagnosis, and treatment of sexually transmitted infections. Deutsches Ärzteblatt International, 113(1-2), 11.

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