Subjective, Objective, Assessment and Plan

Subjective, Objective, Assessment and Plan

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Subjective, Objective, Assessment and Plan

SOAP is a method used by the healthcare practitioners to make notes on a chart of the patient. It is a communication tool that indicates the progress of the patient. With subjective component, the patient is the chief complaint that is CC (Forbes & Watt, 2015). This bit shows the reason for the visit by the patient. For the first time visitation, the practitioners will record the history of present illness that is, HPI. The HPI contains surgical history, social history, medical history and family history, caffeine or drug or alcohol use, allergies, physical activity, smoking status. Objective component composes of information that the health practitioner observes from the patient’s current issue (Forbes & Watt, 2015). It includes vital signs such as weight, results of physical examination, e.g., cardiac and the respiratory and the laboratory results.

Assessment makes a physical diagnosis of the situation making notes on the main symptoms. In this case, a nurse would perform a pelvic exam. The exam would involve a visual exam and pap smear and a manual exam. The results would tell if there are any abnormalities seen and a prescription is given (Forbes & Watt, 2015). The patient’s condition is tested through dark-filled microscopy or a serologic test.

The five conditions to consider for the patient diagnosis differential, in this case, are genital herpes which is characterized by the presence of painful ulcerative lumps around the genitals (Oermann & Gaberson, 2016). The other condition is chancroid which is characterized by the painful ulcer and painful unilateral inguinal lymphadenopathy. Venereal warts condition with symptoms like soft, painless papules. Another condition lymph granuloma venerum-primary stage whose symptoms include painless papule and ulcer. Fixed drug eruption is also another condition to consider in the differential diagnosis.

The additional information to the subjective data is Past medical history: chlamydia 2016.Past Surgical History (PSH): none. Reproductive history: Normal menstruation cycle 28 days. Menarche age 13 with a 3-4 days flow. Personal account: patient denies illicit drug use. ETOH use in social situations- reports an average of 4 drinks a week. Immunization history: immunizations are up to date. Additional objective information include in actual data is to add is the skin felt is cool. The patient avoids direct eye contact. The subjective and objective information supports the assessment. The patients don’t show have any history of cancer and a pap smear carried was usual. The lumps are painless which a characteristic of the chancre.

A diagnostic would be appropriate as it would help differentiate all the conditions for differential diagnosis in this case. The results would provide the exact situation the patient is suffering. This will assist in the administration of the proper medication and prevent future deterioration of the condition in case of the wrong diagnosis (Oermann & Gaberson, 2016).

I accept the diagnosis. There was a test carried to determine the condition that is, the HSV specimen collected. The three possible conditions considered as a differential diagnosis for this patient are genital herpes, chancroid, and venereal warts. Genital herpes characterized by the presence of painful ulcerative lumps around the genitals. The differentiating test is viral culture isolates that will tell if the HSV-1 or HSV-2 is causative in this case (Oermann & Gaberson, 2016). The other condition is chancroid which is characterized by the painful ulcer and painful unilateral inguinal lymphadenopathy. Venereal warts condition is characterized by soft, painless papules.

References

Forbes, H., & Watt, E. (2015). Jarvis’s Physical Examination and Health Assessment. Elsevier Health Sciences.

Oermann, M. H., & Gaberson, K. B. (2016). Evaluation and testing in nursing education. Springer Publishing Company.