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.
- Subjective:
- What other relevant questions should you ask regarding the HPI?
- What other medical history questions should you ask?
- What other social history questions should you ask?
Vaginal Infections
- Objective:
- Explain what POCT will you order and perform, and discuss your rationale for ordering and performing each test.,
- Assessment/ Diagnosis:
- What would be an appropriate diagnosis for her? Why?,
- Any other diagnosis or differential diagnosis you would like to add?,
- Plan:
- 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,
- 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.,
- What patient education is important to include for this patient? (Consider when can the patient resume sexual activity),
- 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.
- Subjective:
- What other relevant questions should you ask regarding the HPI?
- What other medical history questions should you ask?
- What other social history questions should you ask?
- Objective:
- Explain what POCT will you order and perform, and discuss your rationale for ordering and performing each test.
Vaginal Infections
- Assessment/ Diagnosis:
- What would be an appropriate diagnosis for her? Why?
- Any other diagnosis or differential diagnosis you would like to add?
- Plan:
- 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
- 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.
- What patient education is important to include for this patient? (Consider when can the patient resume sexual activity)
- Explain complications that can occur if patient does not comply with treatment regimen.