SOAP Note- Sexually Transmitted Disease
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United States University
Common Illness Across the Lifespan -Clinical Practicum: FNP592
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SOAP Note- Sexually Transmitted Disease
SUBJECTIVE DATA:
ID: A.A is 39-year-old Hispanic Female DOB 03/15/1982. she came to the clinic due to pain and burning sensation that has been going on for the past 10 days. She is a reliable source of information.
Chief Complain “I have been experiencing pain and a burning sensation when urinating. I have also been experiencing a vaginal discharge that has persisted for the past ten days.”
History of present illness: Mrs. Jane Anderson, a 39 years old female, presents to the clinic with complaints of pain in her lower abdomen and a burning sensation whenever she pees. She verbalizes that the condition began about four days. She also added that she had been experiencing urinary urgency and an increased urinary frequency in the past three days. She has been visiting the toiletries around ten times a day. The patient also reported that she has been experiencing a brown vaginal discharge for the past week, and her urine has been having a funky smell after she had unprotected sex with her previous boyfriend. The patient indicated that the urinary frequency and the foul smell distorted her work routine, messing up her concentration at the office where she works as an accountant. Hence, she tried using some pain killers to relent the pain, but they were unfruitful. This made her seek medical attention. According to her suggestion, the pain worsens whenever she urates, and the pain is neither sharp nor dull. She outlined the pain to be on a scale of 8/10 and reported no alleviating or relieving factors to the pain. She admitted to being sexually active but with more than one partner since her husband died. The patient said that her menstrual cycle is also regular, and she experienced it like a week ago and refuted pain during intercourse. She added that she does not have a fever, constipation, nausea, diarrhea, or vaginal bleeding.
Past medical history: The patient suggested that she has been bothered by sexually transmitted diseases like gonorrhoea and chlamydia. She also reported that in her young life, she was bothered by an asthmatic condition.
Surgical: The patient reported that she had undergone surgical procedures in both her young life and adulthood. In her young life, she underwent minor surgery for tooth extraction, while in adulthood, she underwent a caesarean section while delivering her daughter.
LMP: Patient last menstrual period was 10/28/21.
Medications: The patient has been using Advil OTC PRN to regulate her pain.
Allergies: The patient reported that she has not been allergic to food, medications, nor the environment in adulthood, but she was allergic to dust and changes in the environment at a young age.
Immunization: The patient reported that she is up to date with her immunizations, and she last received her flu and covid 19 jabs in April.
Family History: The patient reported that her paternal grandfather is alive and healthy aged 90 years. Her paternal grandmother deceased at the age of 84 due to old age-related comorbidities, and she was subject to diabetes and Alzheimer’s. She reported that both her maternal grandparents are deceased, but they were all healthy. The patient also verbalized that her daughter is healthy.
Social History: The patient is a window for her husband died five years ago and she has not remarried. She lives with her daughter in their rental apartment. She is sexually active but different persons; hence she uses protection but not always. She verbalized that she is an accountant at local finance and investment firm. She suggested that she occasionally drinks three beers, but she does not use recreational drugs. She suggested that she is a Christian and attends masses Sunday morning together with her daughter.
Review of System:
General: The patient denies recent changes in weight, fatigue, nausea, night sweats, chills, or generalized weakness.
HEENT: Head; the patient complained of no headaches. Eyes; she wears glasses due to light, and he does an eye exam every four months. She is negative for glaucoma, diplopodia, floaters, excessive tearing, or photophobia. Ears; she is negative for ear microbes, tinnitus, or oozes from the ears. Nose; her nasal mucosa is pink and negative for any rhinorrhoea. Her olfactory delight is alive, and she is negative for epistaxis. She also has no nasal polyps or any recent sinus infections. Throat and Mouth; she denied gingivitis, gum bleedings, nor any dental deformities. She also reported no hardships chewing or swallowing and sees a dentist after every four months.
Skin: The patient refuted wounds, rashes, bruises, bleeding, lesions, or skin decolouration.
Respiratory: The patient refutes coughs, wheezing, or laboured breathing. She also suggests that she is negative for seasonal allergies.
Cardiovascular: The patient refutes chest pain, edema, racing heart, or orthopnoea.
Gastrointestinal: The patient reported increased lower abdominal pain in the hypogastric region. She denies constipation, nausea, vomiting, diarrhoea, nor alterations in appetite.
Genitourinary/ Gynaecological: The patient reported a burning sensation upon urination, as well as urinary frequency. She suggested that she uses condom as a form of contraceptive and sexually transmitted diseases (STD) control upon coital meetings though not always. She is positive for different sexual partners. She is positive for brownish vaginal discharge after copulation.
Musculoskeletal: The patient refuted joint stiffness, back pain, or dislocations.
Neurologic: The patient reports no seizures, paralyzes, syncope, or changes in memory.
Lymph/Hematology: The patient refuted increased thirst or hunger, irregular temperatures, nor swollen glands.
Psychiatric: The patient reported no depression, sleeping challenges, anxiety, or mood disorientation.
OBJECTIVE DATA
Physical Exam
Vital Signs: Temp- 98.9, Pulse- 75, Resp-18, O2- 98% RA, BP- 122/80, weight-150 lb., height- 5’.6”, BMI-24.2.
General Appearance: The patient reflected a well-nourished adult female who was under no distress. She was well-groomed, alert, and oriented X 4. Her response to queries was straight and logical.
HEENT: Eyes; PERRLA and EOMS intact. Eyes are also conjunctiva clear. Ears; TMs grey/pearly. Nose; pink nasal mucosa, typical turbinates. Neck: Carotids no bruit or jvd. Mouth and Throat; pink and moist oral mucosa with a clear oropharynx.
Skin: The patient’s skin was clean, dry, intact, and normal color reflected her ethnicity.
Cardiovascular: Her S1 and S2 are regular with a normal rate and rhythm. Her heartbeat has no murmurs.
Respiratory: Her chest walls are symmetric, and her respiration is easy and regular. The lungs are clear to auscultation bilaterally.
Gastrointestinal: The patient’s abdomen is flat, soft, non-tender, and non-distended. She has super active bowel sounds in her four quadrants. Upon palpation, there was tenderness in her hypogastric region.
Genitourinary: The patient’s bladder is non distended. However, suprapubic tenderness was noted and some irritations at the labia majora, minora, and vaginal area. There were no ulcerated lesions noted. The lymph nodes were impalpable. The vagina was pink in color but had a funky smell with vaginal discharge noted. Her bimanual examination reflected a friable cervix and positive for CMT. Her uterus was of regular size and shape.
Musculoskeletal: The patient was in a full range of motion in all her extremities.
Neurological: The patient’s speech was clear and logical, with a good tone. Her gait was normal, with a stable balance and an erect posture.
Psychiatric: The patient was alert and oriented, maintaining eye contact when in conversations. She was appropriately dressed for the occasion and responded to queries.
Lab Tests
– Urinalysis- It is significant since it helps outline kidney infections and reflects possibilities of other comorbidities such as diabetes, liver diseases, or kidney diseases.
– A urine culture test would be significant to attest to urinary tract infections (UTI) and identify bacteria or yeasts that are triggering the infections.
– A dipstick urinalysis test was also done for infections where the patient was positive for nitrates and leukocyte esterase.
– Vaginal discharge culture- Gram negative diplococci, Neisseria gonorrhoeae, sensitivities
report pending. Positive monoclonal AB for Chlamydia.
– A Pap smear- A pap smear would also be significant since it would attest for the lower abdominal pain. The test was negative.
– STD tests for gonorrhoea, syphilis, HEP B and C, HIV and chlamydia were ordered.
ASSESSMENT
Differential Diagnoses
Chlamydia ICD-10-CM-A56.8 Chlamydia condition is an STD triggered by the chlamydia trachomatis bacteria (Witkin et al., 2017). At the initial stages of the condition, the condition does not reflect definite symptoms since they manifest in the advanced stages of the condition. Unprotected sex is among the primary methodology of passing the disease, though it does not necessarily contract through penetration (Witkin et al., 2017). The signs that manifest in Mrs. Anderson reflect more of the chlamydia. The condition is closely correlated to having multiple sex partners, previous history of the condition, unprotected sex, and other sexually transmitted diseases. The patient suggested having dysuria and lower abdominal pain, which are among the condition’s primary symptoms. The monoclonal AB test was positive, confirming the chlamydia.
Acute vaginitis ICD-10-CM- N76.0 Vaginitis refers or various disorders that may result in inflammation or vaginal infections. The infections may be caused by multiple organisms like yeast or irritations from chemicals or sprays. The condition is described as the inflammation of the external female genital (Vulva and the Vagina) (Mann et al., 2019). The condition may also result from organisms passed between sexual partners. The condition manifests in slight foul-smelling urine, irregular menses with heavy flow, burning sensation, itching, and the signs worsen with intercourse (Mann et al., 2019). The differential will be disregarded since the patient does not describe pain at intercourse.
Gonorrhoea ICD-10-CM-A54.9 Gonorrhoea is an STD triggered by the Neisseria gonorrhoeae. It primarily affects the warm and moist areas of the body, including the urethra, the eyes, throat, vagina, and anus (Kirkcaldy et al., 2019). The vagina and the anus are the most affected areas by the disorder. The condition can be passed from one person to the other through oral, vaginal, or even anal sex if it is practices unsafe. The symptoms of the condition vary in males and females. The condition in females manifests through vaginal discharge, pain or burning sensation while urinating, sore throats, agony in the lower abdominal area, fever, heavy menses, and pain at copulation (Kirkcaldy et al., 2019). The diagnosis may be disregarded since the patent did not have a prior history of the condition, nor did she have sore throats.
TREATMENT PLAN AND EDUCATION
I would prescribe the patient azithromycin 1g orally as a single dose or doxycycline 100mg twice a day. These dosages should persist for the next seven to 14 days (Phillips et al., 2019). The Food and Drug Administration approves the drug azithromycin as the most effective antibiotic in the treatment of genital chlamydial (Phillips et al., 2019). The dug bars bacterial conditions from multiplying; hence, it is among the most effective drugs in regulating the condition. I would educate the patient to balance her sexual life by practicing safe sex with at least one partner. The patient should also be counselled to protect herself using effective contraceptives such as latex condoms. I will also educate the patient to abstain from sexual activity until she and her partners have completed the prescribed medication.
Follow up
It is important that you keep your follow-up appointment with your provider in 3 months. patient needs to take all her prescribed antibiotics.
References
Kirkcaldy, R. D., Weston, E., Segurado, A. C., & Hughes, G. (2019). Epidemiology of gonorrhoea: A global perspective. Sexual Health, 16(5), 401. https://doi.org/10.1071/sh19061
Mann, A., Mehta, S., & Grover, A. (2019). Acute vaginitis: A rare cause of labial adhesions. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH. https://doi.org/10.7860/jcdr/2019/42259.13271
Phillips, S., Quigley, B. L., Aziz, A., Bergen, W., Booth, R., Pyne, M., & Timms, P. (2019). Antibiotic treatment of chlamydia-induced cystitis in the koala is linked to expression of key inflammatory genes in reactive oxygen pathways. PLOS ONE, 14(8), e0221109. https://doi.org/10.1371/journal.pone.0221109
Witkin, S. S., Minis, E., Athanasiou, A., Leizer, J., & Linhares, I. M. (2017). Chlamydia trachomatis: The persistent pathogen. Clinical and Vaccine Immunology, 24(10). https://doi.org/10.1128/cvi.00203-17
