1 Week 3 SOAP Note- Sexually Transmitted Disease United States University FNP

1
Week 3 SOAP Note- Sexually Transmitted Disease
United States University
FNP xxx: Common Illness Across the Lifespan -Clinical Practicum
Dr. xxxxxxxxx
SOAP Note- Sexually Transmitted Disease
SUBJECTIVE DATA:
Patient Name: C.K
Age: 41-years old,
Gender: Female,
Date of Birth: 03/15/1981
Chief Complain “I have had some pain and burning sensation, especially during urination. The urination has been accompanied by discharges that have been there for the last ten days.”
HPI: This is a 41-year old female patient who visits the facility with the complaints of experiencing lower abdominal pain and some burning sensation during urination. She reported that the problem started four days ago and has been experiencing occasional urges and urgency to urinate for the last three days. According to her, her visits to the toilet can be approximately ten times daily, and whenever she pees, she sees some brown discharge with a funky smell. The problem began after she had unprotected sex with her previous boyfriend. These problems have interfered with her work routine and messed up her focus while in the office where she is employed as an accountant. She reported to have used some painkillers to help in the reduction of the pain, but the pain never disappeared. She also admits that the pain worsens during urination, and it is neither sharp nor dull. She rates the pain as 8/10 and denies any factors that alleviates or relieves the pain. She reported being sexually active and has slept with more than one partner after the death of her husband. She has a regular menstrual cycle and had it a week ago and reported pain during intercourse. She denies fever, nausea, constipation, and vaginal bleeds.
Past medical history: She reported being diagnosed with sexually transmitted infections such as gonorrhea and chlamydia. She is also reported having had asthma disease.
Surgical: She admits to having undergone medical surgery during childhood and adulthood. At a young age, she had tooth removal, while in adulthood, she had a cesarean procedure.
LMP: her last menstrual cycle was on 28th December, 2021
Medications: She has been on Advil OTC as needed to manage her pain.
Allergies: she denies allergic reactions to food, drugs, and the environment in her adulthood. However, she admits experiencing some allergic reactions to dust and changes to the environment during her younger age.
Immunization: Her immunization is up to date, and she was recently vaccinated against flu and covid-19 on April last year.
Family History: The paternal father is alive and healthy at the age of 90 years. The paternal mother is deceased at the age of 84 due to some age-associated comorbidities such as diabetes and Alzheimer’s illness. The maternal grandparents are already dead and did not have any health issues, and the daughter is also healthy.
Social History: She is a widow following her husband’s death for five years ago. She is not having husband yet and is living with daughter in the rental apartments. The patient is active in sexually activities with different boyfriends and uses condom even though this does not usually happen. She is working as an accountant in local investment and financial organization. She admits to being drinking three beers and not using any recreational drug. She is a Christian and always attends Sunday masses in the company of her daughter.
Review of System:
General: Denies any changes to body weight. Denies fatigue, nausea, chills, night sweating, and generalized body weakness.
HEENT: Head; denies any headache. Eyes: She is wearing sunglasses due to the light and denies having any eye examination every four months. Ears; denies any hearing loss. Nose; denies congestion of the nose or bleeding. She has a live olfactory delight and denies epistaxis. Throat and Mouth; the patient denies gingivitis, bleeding of the gums, or dental issues. She admits experiencing some challenges in chewing or swallowing and visits the dental clinic every four months.
Skin: she denies the presence of rashes, bruises, bleeds, lesions, and discoloration of the skin.
Respiratory: Denies coughing, wheezes, breathing difficulties, and seasonal allergies.
Cardiovascular: Denies experiencing chest pain, increased heart rate, and edema.
Gastrointestinal: Admits an increase in the lower abdominal pain within her hypogastric area. Denies experiencing changes in appetite, constipation, nausea, and vomiting.
Genitourinary/ Gynaecological: she admits a burning sensation and frequency in urination. Admits to being using contraceptives or condoms and many sexual partners. Admits vaginal discharges after sexual intercourse.
Musculoskeletal: Denies any stiffness of the joints, back pain, and dislocation of the joints.
Neurologic: Denies any seizures, paralysis, changes in the memory, or syncope.
Lymph/Hematology: She denies an increase in thirst or hunger, irregular temperature, and the presence of swollen glands.
Psychiatric: denies any depression, difficulty sleeping, anxiety, and mood changes.
OBJECTIVE DATA
Physical Examination Vital Signs: Temperature- 99.2, Pulse- 70 beats/minute, Respiration-16, Oxygen Saturation Rate2- 97 percent RA, Blood pressure- 120/75, wt-140 lb., ht- 6’ 1”, Body Mass Index-23.1.
General Appearance: She is a well-nourished female adult and denies distress. She is well well-groomed, alert, and oriented X 4. She is responding well to the questions asked.
HEENT: Eyes; there is intact PERRLA and EOMS. There is clear conjunctiva clear. Ears; there is grey or pearly TMs. Nose; there is pinkish nasal mucosa and typical turbinates. Neck: there is an absence of bruit or carotids. Mouth and Throat; there is pinkish and moistened oral mucosa with oropharynx that is clear.
Skin: The skin is cleaner, dry, intact, and skin color representing her ethnicity.
Cardiovascular: It is expected, regular, and rhythm S1 and S2. There is an absence of murmur in a heartbeat.
Respiratory: there is a symmetric chest wall with easy and regular respiration. There is clear bilateral lung to auscultation.
Gastrointestinal: There is flat, soft, non-tender, non-distended. There is active bowel sounds in all the four quadrants. There is some tenderness within the hypogastric area upon palpitation.
Genitourinary: Non-distended bladder, suprapubic tenderness, irritation within the labia majora, minora, and vaginal region. There is no ulceration of the lesion. There are non-palpable lymph nodes. There is a pinkish vagina with a funky smell of the vaginal discharge. The bimanual examination reveals a friable cervix and position for the CMT. There is the uterus is regular in terms of size and shape.
Musculoskeletal: The motion in all the extremities are in full range.
Neurological: There is clear and sound speech with an excellent tone. The gait is expected with some stability in balance and erected posture.
Psychiatric: She is alert and oriented ×4 and can maintain eye contact during the conversation. She is appropriately dressed for the occasion and responds to questions.
Lab Tests
Urinalysis- the test is essential since it assists in determining the possibilities of kidney infections and reflecting on the possibilities of other diseases like diabetes, liver illness, and kidney illness.
A urine culture test helps reveal the microorganism responsible for the urinary tract infection of the patient.
A dipstick urinalysis test reveals a positive outcome for the nitrates and leukocyte esterase.
Vaginal discharge culture- the test is pending so that the presence of the Gram-negative diplococci and Neisseria gonorrhoeae can be confirmed. The sensitivity test is also pending. There is a positive test outcome for the monoclonal AB for Chlamydia.
A Pap smear- the test was used to determine the problem with lower abdominal pain. The test outcome was negative.
Further laboratory tests for the STDs are ordered to confirm the presence of gonorrhea, syphilis, hepatitis B and C, HIV/AIDs, and chlamydia.
ASSESSMENT
Differential Diagnoses
Chlamydia ICD-10-CM-A56.8: It is a disease that is caused by the presence of the bacteria known as Chlamydia trachomatis (Witkin et al., 2017). The condition is detected in the latest stages since it tends to manifest in the advanced stages. It is caused by having unsafe sex practice with the partner who is already affected (Witkin et al., 2017). The symptoms presented by the patients point to the possibilities of chlamydia. It occurs as a result of having more than one partner, previous diagnosis with the disease, engaging in unsafe sex practices, and having other STDs. The client was confirmed to be having dysuria and pain in her lower abdomen, which are the main signs of the disease. The condition is also further confirmed by the positive outcomes for chlamydia based on the monoclonal AB test.
Acute vaginitis ICD-10-CM- N76.0: This condition leads to inflammation or infection of the vagina. Its etiology is linked to several microorganisms such as yeast or irritations caused by the chemicals or sprays. It is associated with the inflammation of the external female sexual organs, i.e., the vulva and vagina (Mann et al., 2019). It is also caused by the organism that is passed between the partners. It manifests in the form of a slight foul-smell of the urine, irregular menses that occur with heavy flow, burning sensation, itches, and symptoms that worsen after engaging in sexual activities (Mann et al., 2019). Nevertheless, the condition is ruled out since the patient never reported pain symptoms during intercourse.
Gonorrhea ICD-10-CM-A54.9: This is a STI condition caused by Neisseria gonorrhoeae, and it mainly interferes with warm and moist body regions for example urethra and eyes among others (Kirkcaldy et al., 2019). The commonly affected regions are the vagina and the anu. It is spread from one person to another through sexual intercourse, either orally, anal, or vaginal. The symptoms presented by the male patient tend to differ from those represented by the female patient. The manifestation of the disease involves discharges, fever, heavy abdominal pain, production of heavy menses, pain and burning sensation during urination, and pain at copulation (Kirkcaldy et al., 2019). The condition is ruled out because the patient never reported the history of the condition and did not have a sore throat.
TREATMENT PLAN AND EDUCATION
Based on the symptoms presented by the patient, the potential medication that can be described is Azithromycin 1g, which is taken through the oral route as a single dose. The patient can also be given Doxycycline 100mg twice each day. The patient uses the medicines for a period of two weeks (Phillips et al., 2019). The Food and Drug Administration has confirmed Azithromycin as an excellent antibiotic to help in treating genital chlamydia (Phillips et al., 2019). The drug is helping in preventing the multiplication of bacteria. The patient also requires health education, and, in this case, the patient is informed about the importance of balancing the sexual life through engaging in safe sex practices by having not more than one partner. The patient also undergoes a counseling process to ensure that she is protected through effective contraceptives like condoms. Abstinence is another approach to ensure that the patient completes the prescribed medication before sex.
Follow Up
The patient must be monitored throughout the treatment duration. Therefore, the follow-up process will be maintained for the next three months while the patient’s situation is monitored and she adheres to the prescribed medication and instructions.
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