Week Ten: Special Examinations – Breast, Genital, Prostate, and Rectal

Week Ten: Special Examinations – Breast, Genital, Prostate, and Rectal

Your Name
Subject and Section
Professor’s Name
May 1, 2020
For patients that exhibit genitourinary symptoms, in this case, painless lumps, the necessity of clear and comprehensive history documentation is necessary. This must be further probed by a thorough examination of other areas of the body, such as the chest, throat, neck, and rectum. In this paper, the author will present my analysis in four parts. First, an analysis of the subjective data and then provide additional information that must be probed from the patient will be provided. Second, the objective data and introduce other possible tests that must be done to support the diagnostics further will be discussed. Third, the assessment of the diagnosis to check if it coincides with the subjective and objective data will be probed. Lastly, the author will be providing other possible diagnostics for the patient.
Analysis of Subjective Data
The subjective part of this Episodic SOAP note should also include more physical symptoms such as fevers, nausea, vomiting, changes in bowel movement, or discomfort. Furthermore, the patient should be probed further for a more specific description of the bumps, such as their shape, pattern, size and colour, and specific location (inner or outer vulva and the clitoral area). How the bumps were discovered by the patient should also be clarified, as it was not specified if the lumps had hurt at some point before or if other aggravated symptoms led to the discovery of the lumps. Despite the lumps being on the external genitalia, it is also essential to know if she has felt other kinds of discomfort internally. History of other lesions in the genitals and other parts of the body should have also been probed. Hygiene habits for the genital area must also be asked, primarily if the patient uses douches, topical medication, and fragrant soaps.
Skin conditions such as psoriasis, dermatitis, or eczema must be asked from the patient. Asthma management, as well as the age of diagnosis, and if possible immunization records and gynaecological surgeries, must be probed further from the patient.
More importantly, gynaecological history must be documented before a further assessment, in case of a possible pregnancy. A record of the patient's menstrual pattern is vital for this, and thus the date of the last menstrual period, volume, and duration of menstrual flow and contraception use should be checked. Post-coital bleeding—if any should be included, as well as the history of dyspareunia and itchiness in the vulva. Previous dates and duration of medication for STI’s, in this case, Chlamydia, should be documented too.
Since the patient has multiple children, it is necessary to probe her obstetric history. Like the menstrual pattern, this will help assess other possible health risks. 
Analysis of Objective Data
The initial diagnosis of Chancre must be further assessed by doing other tests. Assessment for abnormalities in the throat area, such as redness, other lesions, cold sores, oral thrush, tonsil enlargement must be included on the HEENT exam to check for HSV or other viral infections. Additional information, such as lumps or m..