| SOAP Note | Rationale |
| Demographic Info: Meg P, Chicago, aged 20 years ,Female, unemployed with no insurance cover. |
The demographic information of a patient is important. Young women aged between 18-49 years who are sexually active are at risk of contracting HPV which rarely can cause genital herpes The possession of a medical insurance cover is important to establish the type of medical attention to give a patient. |
| SUBJECTIVE: | |
| CC: severe vaginal itchiness, fluid filled bumps with discharge. | Diagnosis differentials; STD/STI,HPV, |
| HPI: the patient complained of vaginal itching within the last three months. Noticed small fluid bumps that grew bigger with time, the bumps are not painful. Has multiple sexual partners. Experiences bleeding with intercourse. Does oral sex. | At high risk of contacting HPV since is sexually involved with multiple partners. |
| PMHx: the patient was diagnosed with syphilis a year ago and was treated with penicillin. | Syphilis is a sexually transmitted infection and often STIs usually occur together and share similar symptoms. |
| Surgeries: No previous history of surgeries done . | This helps to know whether or not to perform a type of surgery for treatment. |
| OB/GYN: has multiple sexual partners.no pap smear test done previously . | Pap smear test helps to observe abnormal cells around the genital area |
| Fam Hx: has past history of child abuse | This may result to trauma which aggravates with HPV |
| Soc Hx: married with four kids who each have different fathers.works as a bar tender and the job sometimes requires involvement with a person whose sexual history is unknown.lives with her children.has history of daily intake of alcohol. |
Involvement with sexual partners’ wih unknown history is a risk factor for HPV. Alcohol abuse may result to weakened immune system and this is also a risk factor for HPV. |
| Allergies: has no allergies | This helps to know whether or not to recommend a particular drug. |
| Current Meds: doxycycline | On antibiotics for the treatment of recurring syphilis |
| Immunizations: cervarix | Protects against cervical cancer but not genital warts |
| ROS: | |
| General/Constitutional: | |
| HEENT: headaches, trauma, pale eyes, no rashes around the ear, no nose bleeding ,persistent sore throat | This is usually the beginning of a physical exam. |
| Cardiovascular : smokes and also takes alcohol daily, overweight | Factors such as smoking, alcohol abuse with reduced exercise levels and overweight are risk factors of cardiovascular diseases |
| Respiratory: denies incidences of breathing difficulties | Most common in patients with HPV |
| GI: has difficulty in swallowing with sores around the mouth.has good appetite | Gastrointestinal infectons affecting intake and absorption of food. |
| GU: has bleeding with sexual intercourse.has incidences of hematuria[blood in the urine ] | Risk of STD due to unprotected sex with partners with unknown history |
| Musculoskeletal: has muscle joint pain | One of the most common symptoms of HPV |
| Skin: denies painful bumps around the genital area . | HPV bumps are painless |
| Psych: experience anxiety and trauma | Need psychological counseling |
| Neuro; does not have any history of tumors | The HPV 16DNA and protein in the neurons may cause HPV associated tumors[Epub 2006] |
| OBJECTIVE: | |
| VS: bp 113/76,T 37.0 weight 172 height 68 BMI 28 [overweight] |
Normal body temperature, overweight |
| General Appearance: weak and emaciated | To check for physical distress due to the infection |
| Head: experiences headaches ,trauma | It helps to know how to handle the patient since trauma may be as a result of the infection |
| Eyes: pale eyes | Loss of blood especially with sexual intercourse; may be anemic |
| Ears: no excrescences of papilloma around the ear canal | High risk HPV has been identified in the middle ear carcinomas |
| Nose/Sinuses: no discharge on the nasal region ,no nose bleeding | One of the major symptoms of HPV. |
| Mouth: a swollen lump in the mouth | Oral HPV has been known to cause sores around the mouth resulting to difficulty in chewing or swallowing |
| Neck: a swollen but painless tonsil | This may result to poor intake of food and also drugs. |
| A persistent sore throat /hoarse voice | |
| Heart: the heart beat rate is normal | HPV could cause increased pulse rate |
| Lungs: experiences difficulty in breathing | Increased respiratory rate |
| Abdomen : no abdominal tenderness at the lower part, | Helps identify other possible signs |
| Extremities: heavy bleeding during and after sexual contact | As a result of the HPV infectious virus |
| Skin : itching and discomfort around the genital area | STD/STI[syphilis, chlamydia, gonorrhea] |
| Neuro: experiences headaches,trauma | HPV infection may cause headaches and trauma and other flu-like symptoms. |
| Laboratory & Diagnostic Testing: | |
| Colposcopy and acetic acid test | To examine the cervix,vagina after application of acetic acid solution |
| PCR | To determine reproducibility of HPV sequences. |
| biopsy | to determine presence of dysplasia or cancer |
| ASSESSMENT: | |
| STI[other STIs] gonorrhea and chlamydia | Itchy vagina with discharge |
| Cervical cancer | Most common complication of HPV |
| At risk of contracting HIV |
Has multiple sexual partners Unprotected sexual intercourse |
| Dysplasia[changes in the precancerous changes to the cells of the cervix] | Possible complication of HPV |
| PLAN: | |
| Perform an electro cautery or surgery[excision]-to cut out the wart using scissors. | To destroy the wart under local anesthetic |
| Perform a cervical pap smear screening test | To test for cervical cancer since it is a possible complication of HPV infections |
| Test for HIV | It is recommended for sexually active patients with vaginal discharge and itchiness |
| counseling | Use protection such as condoms |
| imiquidone 1% | To treat HPV |
| COMMENTS: | |
| Genital warts caused by Human papilloma virus | As a result of unprotected sex with multiple sexual partners/oral sex |
References
Das, S., Chowdhury, J., Patra, S., Ghoshal, L., & Banerjee, S. (2017). Auto-wart inoculation: An easy and effective treatment of multiple, recalcitrant and genital warts. Journal of Pakistan Association of Dermatology , 26 (3), 229-234.
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Hu, Z., Liu, L., Zhang, W., Liu, H., Li, J., Jiang, L., & Zeng, K. (2018). Dynamics of HPV viral loads reflect the treatment effect of photodynamic therapy in genital warts. Photodiagnosis and photodynamic therapy , 21 , 86-90.
Yuan, J., Ni, G., Wang, T., Mounsey, K., Cavezza, S., Pan, X., & Liu, X. (2018). Genital warts treatment: beyond imiquimod. Human vaccines & immunotherapeutics , 14 (7), 1815-1819.
