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Tag Archives: Any other diagnosis or differential diagnosis you would like to add?

March 13, 2025
March 13, 2025

Vaginal Infections

Lisa is a 19-year-old female who presents to the clinic c/o abnormal vaginal discharge for one week after having unprotected vaginal intercourse with a new male partner she has been dating for a couple of weeks.  Lisa’s pregnancy test is negative and her LMP was 2 weeks ago. As her health care provider, you will need to perform testing to determine if Lisa has contracted a sexually transmitted infection or other vaginal infection.

 

Vaginal Infections

 

Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.

  1. Subjective:
    1. What other relevant questions should you ask regarding the HPI?
    2. What other medical history questions should you ask?
    3. What other social history questions should you ask?

Vaginal Infections

  1. Objective:
    1. Explain what POCT will you order and perform, and discuss your rationale for ordering and performing each test.,
  2. Assessment/ Diagnosis:
    1. What would be an appropriate diagnosis for her? Why?,
    2. Any other diagnosis or differential diagnosis you would like to add?,
  3. Plan:
    1. What will you prescribe for this patient? Why? (assume one of your lab test results is positive) Explain what medications and treatments you would recommend,
    2. Explain treatment guidelines and side effects including any possible side effects of the medication and treatment(s) partner notification and follow-up plan of care.,
    3. What patient education is important to include for this patient? (Consider when can the patient resume sexual activity),
    4. Explain complications that can occur if patient does not comply with treatment regimen.

Vaginal Infections

Lisa is a 19-year-old female who presents to the clinic c/o abnormal vaginal discharge for one week after having unprotected vaginal intercourse with a new male partner she has been dating for a couple of weeks.  Lisa’s pregnancy test is negative and her LMP was 2 weeks ago. As her health care provider, you will need to perform testing to determine if Lisa has contracted a sexually transmitted infection or other vaginal infection.

Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.

  1. Subjective:
    1. What other relevant questions should you ask regarding the HPI?
    2. What other medical history questions should you ask?
    3. What other social history questions should you ask?
  2. Objective:
    1. Explain what POCT will you order and perform, and discuss your rationale for ordering and performing each test.

Vaginal Infections

  1. Assessment/ Diagnosis:
    1. What would be an appropriate diagnosis for her? Why?
    2. Any other diagnosis or differential diagnosis you would like to add?
  2. Plan:
    1. What will you prescribe for this patient? Why? (assume one of your lab test results is positive), Explain what medications and treatments you would recommend
    2. Explain treatment guidelines and side effects including any possible side effects of the medication and treatment(s), partner notification, and follow-up plan of care.
    3. What patient education is important to include for this patient? (Consider when can the patient resume sexual activity)
    4. Explain complications that can occur if patient does not comply with treatment regimen.
December 6, 2024
December 6, 2024

Menstrual Patient SOAP Note

Kelly is a 19-year-old female who comes to your clinic complaining of severe menstrual pain that is usually worse just prior to and during the first two days of her menses. The pain is sometimes so severe that she has fainted. She states that defecation can cause severe pain and she therefore frequently becomes constipated. She often must miss work when experiencing the severe pain. Her periods are heavy and last seven days with a tapering of the bleeding from days 3 to 7. Her BMI is 23.9 and her VS are all WNL. She is G0 P0.

 

Menstrual Patient SOAP Note

Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.

  1. Subjective:
    1. What other relevant questions should you ask regarding the HPI?,
    2. What other medical history questions should you ask?,
    3. What other social history questions should you ask?,
    4. What other family history questions should you ask?,
  2. Objective:
    1. Write a detailed focused physical assessment on this patient.,
    2. Explain what test(s) you will order and perform and discuss your rationale for ordering and performing each test.,
  3. Assessment/ Diagnosis:
    1. What is your presumptive diagnosis? Why?,
    2. Any other diagnosis or differential diagnosis you would like to add?,
  4. Plan:
    1. How will you manage this patient? What treatment or medication would you prescribe and why?,
    2. Explain treatment guidelines and side effects including any possible side effects of the medication and treatment(s),
    3. What patient education is important to include for this patient? (Consider including pharmacological, supplements, and non pharmacological recommendations and education)
    4. What is the follow-up plan of care?
    5. Explain complications that can occur if patient does not comply with treatment regimen.

Please refer to evidence-based guidelines to support your decision-making. Menstrual Patient SOAP Note

Kelly is a 19-year-old female who comes to your clinic complaining of severe menstrual pain that is usually worse just prior to and during the first two days of her menses. The pain is sometimes so severe that she has fainted. She states that defecation can cause severe pain and she therefore frequently becomes constipated. She often must miss work when experiencing the severe pain. Her periods are heavy and last seven days with a tapering of the bleeding from days 3 to 7. Her BMI is 23.9 and her VS are all WNL. She is G0 P0. Menstrual Patient SOAP Note

Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.

  1. Subjective:
    1. What other relevant questions should you ask regarding the HPI?
    2. What other medical history questions should you ask?
    3. What other social history questions should you ask?
    4. What other family history questions should you ask?
  2. Objective:
    1. Write a detailed focused physical assessment on this patient.
    2. Explain what test(s) you will order and perform, and discuss your rationale for ordering and performing each test.
  3. Assessment/ Diagnosis:
    1. What is your presumptive diagnosis? Why?
    2. Any other diagnosis or differential diagnosis you would like to add?
  4. Plan:
    1. How will you manage this patient? What treatment or medication would you prescribe and why?
    2. Explain treatment guidelines and side effects including any possible side effects of the medication and treatment(s),
    3. What patient education is important to include for this patient? (Consider including pharmacological, supplements, and non pharmacological recommendations and education)
    4. What is the follow-up plan of care?
    5. Explain complications that can occur if patient does not comply with treatment regimen.

Please refer to evidence-based guidelines to support your decision-making.