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The SOAP Note Analysis Assignment Paper

The SOAP Note Analysis Assignment Paper

Subjective Portion Analysis

In order to develop a diagnosis based on subjective information, an additional detailed recording of the pertinent positives and negatives is required. Therefore, the practitioner needs to ensure that the following items are included in the subjective portion. A comprehensive ROS is required. The ROS relies on the practitioner conducting an in-depth conversation with the patient in order to collect information that would aid in the correct diagnosis (Hollier, 2021)The SOAP Note Analysis Assignment Paper. There has to be a detailed account of how the patient is feeling in terms of pain. It is important to keep a record of how severe the dysuria and the flank pain are. It is also crucial to record any accompanying symptoms, like a fever, headache, vomiting, or nausea. Documentation of sexual activity or reproductive history is necessary. No information on the patient’s history was provided, including their history socially, financially, professionally, or in terms of their contact with secondhand smoke. Neither the client’s hobbies nor her strategies for dealing with stress were recorded. It is necessary to record both the client’s history of tobacco or alcohol use and their usage of illegal substances. Factors that alleviate pain should also be recorded in the HPI.

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Objective Portion Analysis

The objective section of the SOAP note had very little information that would aid in diagnosis. Assessing the genitalia as well as the rectum as part of a pelvic exam is essential for a precise diagnosis. It is also essential to record the following information in the objective portion: The SOAP Note Analysis Assignment Paper

  • Genital and vaginal assessment for the presence of lumps, sores, warts, abscesses, or other abnormalities
  • Urethral meatus assessment excludes the possibility of discharge, tumors, caruncles, cysts, or anal fissures.
  • Perineal assessment to check for any signs of damage or irritation
  • Vaginal mucosal assessment to evaluate pinkness and moisture level
  • Vaginal palpation involves checking the vaginal walls for tenderness or smoothness. Additionally, check for the presence of any tumors, lumps, or cysts. The SOAP Note Analysis Assignment Paper

Is the assessment supported by subjective and objective information?

There is solid evidence to back up TS’s diagnosis of UTI from the subjective data. Symptoms of a UTI that she describes include pain, painful urination, and frequency. TS further reports feeling pain in her back and suprapubic region, all of which are typical symptoms of a urinary tract infection. Based on the objective information presented, there is a good chance that TS is suffering from a UTI rather than an STI. Certain STIs, however, is well-known for showing no outward symptoms until a late stage of the infection, after which they may cause serious problems or even mortality (Czajkowski et al., 2021)The SOAP Note Analysis Assignment Paper. The four most prevalent sexually transmitted infections (STIs) that TS should be tested for are gonorrhea, chlamydia, trichomoniasis, and human papillomavirus.

Diagnostic Testing

Because a UTI may develop from an STI and vice versa, the patient has to get both conditions checked out. In order for a doctor to determine whether a sort of bacteria is contributing to the symptoms, a urinalysis and culture may be performed to test for both kinds of infections. If the medical professional is aware of the species of bacteria present in the patient’s urine, they will be more equipped to treat the condition (Ozkan et al., 2018)The SOAP Note Analysis Assignment Paper. It is possible to determine if the bacteria is from a sexually transmitted infection such as chlamydia or gonorrhea by using an antibody-coated bacteria test. The symptoms of a sexually transmitted infection might mimic those of cystitis if the proper diagnostic test is lacking.

 Reject/accept the current diagnosis

The diagnosis of a urinary tract infection is one that I would agree with. Frequent urination and a burning sensation during urination are typical signs of a UTI. I am open to the possibility of the diagnosis of STI. Painful urination, lower abdominal pain, fever, and vaginal secretions are all indications of a sexually transmitted infection. Although the patient is complaining of pain, it is not in the lower abdomen but rather in her flank. She also denies having any vaginal discharge.

Differential Diagnosis

  • Acute Pyelonephritis: This is a bacterial infection that causes inflammation of the kidneys, and it may spread to other organs. It is a complication of a urinary tract infection that travels up the urinary tract and affects the kidneys (Ball et al., 2019)The SOAP Note Analysis Assignment Paper.
  • Pelvic Inflammatory Disease: This is an infection that affects the reproductive system, namely the uterus, fallopian tubes, and ovaries. Pelvic and abdominal pain, discomfort during sexual activity, and painful or frequent urination are indications of this illness.
  • Chlamydia: Most of the women who seek medical care for STIs have this bacterial infection. In most cases, no symptoms are seen with this illness. As a consequence, people might go longer without interventions, increasing their risk of complications such as fertility problems, ectopic pregnancy, and pelvic inflammatory disease(Dubbink et al., 2018)The SOAP Note Analysis Assignment Paper.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination (9th Ed.). St. Louis, MO: Elsevier Mosby.

Czajkowski, K., Broś-Konopielko, M., & Teliga-Czajkowska, J. (2021). Urinary tract infection in women. Przeglad menopauzalny = Menopause review, 20(1), 40–47. https://doi.org/10.5114/pm.2021.105382

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Dubbink, J. H., Verweij, S. P., Struthers, H. E., Ouburg, S., McIntyre, J. A., Morré, S. A., & Peters, R. P. (2018). Genital Chlamydia trachomatis and Neisseria gonorrhoeae infections among women in sub-Saharan Africa: A structured review. International Journal of STD & AIDS, 29(8), 806–824. https://doi.org/10.1177/0956462418758224

Hollier, A. (2021). Clinical guidelines in primary care. Advanced Practice Education Associates.

Ozkan, I. A., Koklu, M., & Sert, I. U. (2018). Diagnosis of urinary tract infection based on artificial intelligence methods. Computer Methods and Programs in Biomedicine, 166, 51-59. https://doi.org/10.1016/j.cmpb.2018.10.007 The SOAP Note Analysis Assignment Paper