SOAP Note for the Genitalia/Rectum

Week 10 focuses on breast, genitalia, prostate, and rectum.  The learning objectives for this week include:  

  • Evaluate abnormal findings on the genitalia and rectum 
  • Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the breasts, genitalia, prostate, and rectum 

The assignment for this week is an analysis of a SOAP note for the genitalia/rectum. As in the previous SOAP note analysis, this should be completed in a narrative format and answer all the questions listed in the assignment within the module.  Please remember to use the rubric to complete the assignment.   

Genitourinary Assessment: 

  • Subjective: 
  • CC: Increased frequency and pain with urination 
  • HPI:  T.S. is a 32-year-old woman who reports that for the past two days, she has dysuria, frequency, and urgency. Has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months. 
  • Medical History:  None 
  • Surgical History: 

-Tonsillectomy in 2001 

-Appendectomy in 2020 

  • Review of Systems: 
  • General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm. 
  • Abdominal: Denies nausea and vomiting. No appetite 
  • Objective  
  • VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg. 
  • Pelvic Exam: 

mild tenderness to palpation in the suprapubic area 

bimanual pelvic examination reveals a normal-sized uterus and adnexae 

no adnexal tenderness. 

No vaginal discharge is noted. 

The cervix appears normal. 

  • Diagnostics:  
  • Urinalysis 
  • STI testing  
  • Papsmear 
  • Assessment: 
  • UTI 
  • STI 

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. 

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