Walden University The SOAP Note Discussion

Respondtoatleasttwo of your colleagues’ posts on two different days and explain how you might think differently about the types of tests you might recommend and explain why. Use your Learning Resources and/or evidence from the literature to support your position.

Reply to the SOAP note below:

Patient Information:

CB, 22, F, not mentioned

S.

CC: burning + discharge

HPI: CB is a 22 yo female who presents to the clinic today for burning and discharge for 1 week. She states her boyfriend recently found out he was positive for chlamydia. She denies any other partners besides him.

Current Medications: – Srintec PO Daily for birth control – Multivitamin PO Daily

Allergies: NKDA, no environmental or food allergies

PMHx: No past medical historySoc & Substance Hx: Social alcohol use, but denies tobacco or recreational drug use.-currently in a monogamous relationship w/ boyfriend

Fam Hx:-Mother: alive w/ breast cancer in remission and hypothyroidism-Father: HTN, DM2, HLD-Paternal grandfather: alive w/ prostate CA-Sister: DM1-Brother: no PMHx

Surgical Hx: No surgical hx

Mental Hx: Endorses hx of anxiety and depression. No hx of SI/HI, or self-harm

Violence Hx: Concern or issues about safety (personal, home, community, sexual—current and historical).

Reproductive Hx: G0P0L0, LMP: unknown, Srintec for BC, types of intercourse unknown, male sexual preference.

ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: Endorses a history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.

GENITOURINARY/REPRODUCTIVE: Burning on urination w/ discharge. Denies breast lumps, pain, and discharge.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Physical exam

· Height 5’ 5” Weight 148 (BMI 24.6), BP 132/68 P 62

· HEENT:  WNL

· Neck: lymph nodes grossly normal

· Lungs/CV: Chest is clear to auscultation bilaterally, normal respiration, rhythm, and depth upon exam

· Breast: normal breast exam

· Abd: WNL

· VVBSU: WNL

· Cervix: firm, smooth, yellow watery discharge in large amount present

· Uterus: RV, mobile, non-tender

· Adnexa: WNL

Diagnostic results:

• NAAT of endocervical/vag/ urethral swab or first catch urine sample, and if indicated rectum/oropharynx swab if indicated
• Wet mount microscopy of vaginal secretions
• STI panel: syphilis, GC, HIV, hep B, trichomonas
• Upreg

A.1. Chlamydia2. Gonorrhea3. Bacterial Vaginosis

ExplanationThe tests mentioned above are essential to rule out other STDs. When a patient presents with suspected chlamydia infection, a workup for other STDs should be carried out to avoid further complications such as PID that may lead to infertility (Mohensi & Takov, 2022). A urine pregnancy test should be performed because doxycycline is the first line of treatment for chlamydia but is contraindicated in pregnancy. Also, this test is indicated because the patient confirms the partner has already tested positive, making this the likely diagnosis. Gonorrhea is a differential diagnosis because chlamydia and gonorrhea can coexist in males. It is unclear if this patient engages in anogenital sex or oral sex; if so, screening is required from the anus, urogenital, and pharynx by collecting samples for a NAAT (Springer &Salen, 2022). The patient denies a foul odor but endorses dysuria and vaginal discharge. A wet mount is required to rule out bacterial vaginosis. STDs including chlamydia can accompany BV. The wet support is a diagnostic tool for BV but can also aid in ruling out the presence of yeast or trichomonas (Kairys & Gard, 2022).

Additional Questions

• Does your partner have sex with partners other than you?
• When was your partner diagnosed with chlamydia? Has he been prescribed antibiotics? Is he taking the antibiotics?
• Does your partner use condoms?
• What kind of sexual contact do you engage in (anal, oral, genital)?
• Do you feel safe in your relationship?
• Do you use sex toys? If so, do you clean toys after use, and how do you clean them?
• Any history of vaginal infections? Type of treatment received and date of the last infection.
• Do you remember to void after sex?
• Do you experience any urinary or stool incontinence?
• Are you experiencing any fever or chills?
• How do you clean your genitalia and rectal area? Do you douche, use scented cleansers or lotions?

References

Kairys N, Garg M. Bacterial Vaginosis. [Updated 2022 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK459216/

Mohseni M, Sung S, Takov V. Chlamydia. [Updated 2022 Apr 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK537286/

Springer C, Salen P. Gonorrhea. [Updated 2022 Apr 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK558903/