Review the Case Study: Petunia Park

Soap Note Template is a document that is utilized by physicians to record a patient’s assessment. The soap Note ensures that the information about the patient is consistent regardless of the care provider on the shift. It ensure that the care provider can easily find and refer from the most relevant clinical and patient data during treatment or diagnosis. Completing a Soap Note means you can effectively communicate and record a patient’s information.

You will use this case as the basis of this Assignment.

Consider what history would be necessary to collect from this patient. Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

• Subjective: What details did the patient provide regarding their chief complaint and symptomatology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
• Objective: What observations did you make during the psychiatric assessment?
• Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
• Reflection notes: What would you do differently with this client if you could conduct the session again? Discuss what your next intervention would be if you were able to follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

SOAP NOTE Exemplar

Name: AB

Age: 21

Sex: Female

CC (Chief complaint): I have bumps on my bottom that I want to have checked out.

HPI: AB is 21-year-old who studies in WF college. AB presented herself in the clinic complaining of rough and painless bumps on her genital area. The onset of the bumps has been approximately a week ago. AB reports that she has been sexually active with two partners over the past one year. She also had a history of asthma and chlamydia two years ago with completed treatments. She reported being sexually active since she was 18 years.

Current medications: symbicort 160/4.5mcg PO twice daily

Allergies: NKDA

Past Medical History: Asthma, chlamydia

Family history: No hx cervical or breast cancer, mother and father hx HTN

Social history: Denies the use of tobacco. Ab is married with three children one boy and two girls. Occasional ETOH

ROS:

General: Denies fever, weight loss, weakness and fatigue.

HEENT: Eyes: Denies blurred vision, visual loss, yellow sclera and double vision.

Eyes, Throat, Nose: Denies sore throat, runny nose, hearing loss and congestion.

Skin: Report bumps around the genital area, no vaginal discharge reported.

Respiratory: Denies cough, shortness of breath or sputum.

Cardiovascular: Denies chest discomfort, chest pressure, chest pain.

Gastrointestinal: Denies Nausea, anorexia, diarrhea, vomiting. No blood or abdominal pain.

Neurological: Denies dizziness, headache, syncope, ataxia and paralysis

Allergies: History Asthma, denies eczema, hives or rhinitis.

Physical exam:

Vital signs: B/P 120/86; Temp 98.6; WT 169lbs, RR 16; HT 5’10”

General: Oriented X4 female, alert, awake. She is well nourished and gloomed. Denies chills, fever, weakness, vomiting, nausea and fatigue.

Cardiovascular: S2 +S1, rhythm regular, heart no peripheral edema and no murmur observed.

Respiratory: Chest wall symmetrical and CTA

Gastrointestinal (Abd): Normoactive bowel sounds, abdomen soft, neg rebound, neg McBurney, neg murphy’s

Genitourinary: Normal female hair pattern distribution, no swelling or masses. Urethral meatus intact without discharge or erythema. Perineum intact with a present episiotomy scar.

Diagnostic results: The results for HSV specimen obtained.

Differential diagnoses

• Human Papiloma Virus (HPV)- HPV infection is generally caused by warts. Some HPV infections lead to cervical cancers. There are more than 100 categories of HP (Hammer and McPhee, 2014). Ideally, most the HPV infections may not cause cancer. However, some various categories of genital HPV may lead to cervical cancer. HPV infection may be liable for cancer of the penis, anus, vagina, orophatyngeal and vulva.

Signs and symptoms

The immune system of the body is able to combat the HPV before creation of warts. Ideally, when warts form, the vary in appearance depending with the category of HPV involved: common warts, genital warts, plantar warts and flat warts (Hammer and McPhee, 2014). In women genital warts appear mostly on the vulva but may also form near the cervix, anus and vagina.

Diagnostic tests: The following tests may be recommended in case the genital warts do not appear.

• Solution and Acetic acid test: This entails vinegar solution that are smeared to the HPV infected genital region and makes these areas white (Hammer and McPhee, 2014).
• Pap smear: This comprises of a clinical collecting sample of cells from the vagina and cervix to send the laboratory analysis. Ideally, a pap test may be show abnormal cells that may cause cancer (Hammer and McPhee, 2014).
• DNA test: Comprises of analyzing cells from the cervix of the patient and is able identify the DNA that is viewed as a high risk of HPV and connected to genital cancers (Hammer and McPhee, 2014). 

• Genital Herpes: This is a STI that is led by the herpes simplex virus (Goljan, 2014). Ideally, the virus is transmitted. The virus typically lies dormant and may result several times a year (Goljan, 2014).

Sign and symptoms: Symptoms may start between two to ten days after exposure of the HSV. Symptoms include; itching or pain in the genital area, white blisters, red bumps, ulcers that my bleed or ooze and scabs (Goljan, 2014).

Diagnostic Tests: A clinician may identify genital herpes by the physical examination along with causes of some of the following results: Polymerase chain reaction test, viral culture of the sore, HSV antibody test

• Bartholin cyst: This is located to one of the sides of the vaginal openings with a secreted fluid that enables the vaginal to lubricate (McCance et al., 2014). When the openings are obstructed, the fluid will back up to the glands. This will lead to swelling known as Bartholin cyst. The fluid then becomes puss due to infection which then becomes abscess (Hammer and McPhee, 2014).

Signs and symptoms: The cyst may lead to mass or lumps near the opening of the vagina. When a cyst gets infected the following signs and symptoms appear: pain during sexual intercourse, discomfort while sitting or walking. A painful, tender lump near the vaginal opening and fever.

Diagnostic tests: Diagnosis of the Bartholin cyst may be done through health history, acquiring sample of emissions from the vagina, pelvic examination and biopsy from the women at the age of 40 years and above.

• Sebaceous cysts: The Sebaceous cysts are considered as abnormalities that occur within the body that contain noncancerous liquid (McCance et al., 2014). These mostly occur on the neck, face or torso. Their growth is not fast and they are not life threatening but are found to be uncomfortable to the patient if untreated.

Signs and symptoms: Large cysts are painful while the small cysts are not painful. The large cysts on the neck, face and neck can lead to pain and pressure. The regions of the body where there are cysts are usually on the neck, scalp, back and face (McCance et al., 2014).

Diagnostic tests: This can be done during physical examination. In case the cysts are considered abnormal the clinician may decide to test them in order to rule out cancer. The common tests involve Ultra sounds for internal structure of biopsy and cysts, CT scans to evaluate possible cancers.

• Syphilis: This is a bacterial infection that is caused primarily by sex (McCance et al., 2014). It has a painless sore on the mouth, genitals and rectum. Syphilis may spread via mucous and skin membrane contact with the sores. Syphilis can remain dormant for a number of decades before the resurface (Hammer and McPhee, 2014).

Signs and symptoms: Syphilis is presented in a number of stages which include secondary, primary, tertiary, latent and congenital syphilis.  The primary syphilis is the first sign of syphilis which is a small sore that occurs as spot where the bacteria has entered the body. The secondary syphilis occurs within a few weeks where they experience rashes that cover the entire body. Latent syphilis remains dormant for decades if left untreated while the tertiary syphilis is the last stage where the disease may damage eyes, brain, heart, nerves and blood vessels.

Diagnostics: Serum tests are used to confirm the antibodies that are produced by the body to fight the infections. The antibodies that are formed can cause the infection to remain in the body for a year. Cerebral spinal fluid: If it has been presumed that the nervous system has been affected by syphilis a lumbar puncture may be suggested.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Goljan, E. F. (2014). Rapid review: Pathology (4th ed.). Philadelphia, PA: Elsevier.

Hammer, G. D., & McPhee, S. J. (2014). Pathophysiology of disease: An introduction to clinical medicine (7th ed.). China: McGraw Hill.

McCance , K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2014). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, MS: Elsevier.