A) Please fallow instruction. I need you to make up a soap note for a female patient with diagnoses of Genital Herpes. Please fill out the template. I include the soap note template and use it as a sample, this is the way it has to come out. you must plug the information. do not use the same he same words nor the same vital signs in the sample template, you. make up your own vital sign I need you to provide the following: APA format with references at least no older than 5 years.
- 1)The Diagnosis ICD 10 code
- 2) 3 differential diagnoses with ICD 10 code.
- 3)Vital sign, BMI
- 4)Complete Chief patient compliant
- 5)Subjective Information
- 6)PMH, PSH, FH, ROS completed. Provide complete and concise summary of pertinent information.
- 7)Complete Objective Information
- 8)Lab Tests
- 9)Allergies
- 10)Complete physical exam with critical elements related to subjective data.
- 11)Perform Assessment
- 12)Minimum of 3 differentials supported by S + O data. Final diagnosis noted and optimal and thorough subjective and objective assessment is presented for final diagnosis.
- 13)Create a Plan
- 14)Plan includes pharmacologic and nonpharmacologic treatments as well as education provided. The plan is supported by evidence/guidelines, and the follow-up plans are noted.
- 15)Self-Assessment & Clinical Guidelines
- 16)Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence based reasoning and literature in designing plan of care, compare to plan of care.
B) Discuss of Genital Herpes.Etiology, pathophysiology, sign and symptomps,Pharmacological and non-pharmacolgical treatments, education and prognosis.
Expert Solution Preview
Introduction:
The following is a SOAP note for a female patient with a diagnosis of genital herpes. The SOAP note includes the patient’s information, diagnosis, differential diagnoses, vital signs, chief complaint, subjective and objective information, lab tests, allergies, physical examination, assessment, plan, self-assessment, clinical guidelines, and prognosis. Additionally, this paper will also discuss genital herpes, including its etiology, pathophysiology, signs and symptoms, pharmacological and non-pharmacological treatments, education, and prognosis.
A) SOAP Note:
Diagnosis ICD 10 code: A60.9
Differential diagnoses with ICD 10 code:
1. Syphilis – A51.9
2. Chancroid – A57.1
3. Granuloma inguinale – A58.9
Vital sign, BMI: Blood pressure – 120/80 mmHg, Pulse rate – 80 bpm, Respiratory rate – 18 breaths per minute, BMI – 23.5 kg/m².
Complete Chief Patient Complaint: The patient complained of painful vesicular lesions in the genital area.
Subjective Information: The patient reported experiencing a burning sensation while urinating. There was also an onset of painful vesicular lesions that were very distressing. The patient has been sexually active with multiple partners in the past and had unprotected sex. She also mentioned feeling embarrassed about her condition and was concerned about the implications for her personal and professional life.
PMH, PSH, FH, ROS completed:
PMH- No significant medical history is present.
PSH- No significant surgical history is present.
FH- No significant family history is present for sexually transmitted diseases.
ROS- Negative for headaches, fever, malaise, joint pains, rash, swelling, vomiting, or diarrhea.
Complete Objective Information:
General: The patient was alert and oriented with no acute distress.
Skin: The genital area had clustered vesicles in various stages of development with painful erosions present.
Cardiovascular: Regular rhythm without any murmur or gallop.
Respiratory: Normal breathing effort with clear breath sounds.
Abdomen: Soft and non-tender with no hepatosplenomegaly.
Extremities: Peripheral pulses were strong and symmetrical.
Lab Tests: Genital swab for PCR testing was positive for herpes simplex virus.
Allergies: The patient has no known allergies.
Complete Physical Exam with critical elements related to subjective data:
The genital area had clustered vesicles in various stages of development with painful erosions present. There was no inguinal lymphadenopathy noted.
Perform Assessment:
Final diagnosis: Genital Herpes
Differential diagnosis: Syphilis, Chancroid, Granuloma inguinale.
Plan:
Pharmacological treatments- Acyclovir 800 mg five times daily for seven days.
Non-pharmacological treatments- The patient was advised to keep the affected area clean and dry and avoid sexual contact until the lesions are healed.
Patient Education- Counseled about genital herpes and its potential complications. Advised to use condoms for future sexual encounters and contact all of their sexual partners to inform them of the diagnosis.
Follow-up plans- The patient was advised to return for a follow-up in seven to ten days, and if symptoms persist, she was instructed to notify their healthcare provider.
Self-Assessment & Clinical Guidelines:
Based on the signs and symptoms, lab test and physical examination, genital herpes was the most likely diagnosis, which was supported by guidelines from the CDC.
B) Genital Herpes:
Etiology: Genital herpes is caused by herpes simplex virus (HSV). There are two types of HSV, type 1 and type 2. Type 1 usually causes oral herpes, and type 2 primarily causes genital herpes. However, both types can cause either form of the disease.
Pathophysiology: The virus penetrates the skin or mucous membranes and enters the sensory nerves. The virus then migrates to the ganglia and becomes latent. Periodically, the virus reactivates and travels down the nerve to the skin or mucous membrane of the region innervated by the nerve resulting in blistering painful lesions.
Signs and Symptoms: The signs and symptoms of genital herpes vary but include painful vesicles in the genital area, urethritis, dysuria, and fever. The infection starts as vesicles that rapidly progress to ulcers and within two weeks heal by scarring or sloughing off, thereby resulting in a cycle of ulceration, heal and recurrence.
Pharmacological Treatment: Antiviral drugs such as Acyclovir, Valacyclovir, and Famciclovir are effective in reducing the frequency, duration and severity of recurrences. Acyclovir is approved for both initial and recurrent episodes of genital herpes along with valacyclovir and famciclovir.
Non-pharmacological Treatment: It is recommended to maintain good hygiene in the genital area during the outbreaks and avoid sexual contact until the ulcers are completely healed. Also, do not touch the ulcers and try to keep the infected area dry.
Education and Prognosis: Counseling and teaching the patient about the nature of the disease, mode of transmission, safe sex practices, and describing the potential complications that may arise due to the disease is important. Although genital herpes is a chronic infection, it is generally a benign and self-limiting disease with a favorable prognosis.
