Focusedsoap note on gynecologic health: Case Study 1, week 3, NRNP 6552.
C. B, 22 years old, Female, Caucasian.
CC (chief complaint): The patient complained of a burning sensation during urination and vaginal discharge for one week
HPI: C. B., 22 years- old female patient, presented with a complaint of a burning sensation ring urination and has been having yellow watery vaginal discharges for a week. Patient-reported her boyfriend recently tested positive for chlamydia, and she is worried. The patient also reported having only one sexual partner and has not had sexual contact with anyone else.
Current Medications: The patient reports she takes Srintec oral contraceptives daily and multivitamins.
Allergies: No known drug allergies, no known food allergies.
PMHx: The patient record shows she is fully vaccinated and has recently gotten her flu shot for this year, and is up to date with the covid vaccine. The patient has a past medical history of depression and anxiety but is not on medications.
Soc & Substance Hx: the patient reports she is a social drinker, has never smoked, and has never used recreational drugs. The patient lives at home with her mom and siblings and works.
Fam Hx: mother is alive with breast cancer in remission and hypothyroidism. Her paternal grandfather is alive with prostate cancer. Her sister has type 1 diabetes as well. Her father has HTN, diabetes type 2, and hyperlipidemia.
Surgical Hx: No prior surgical history reported.
Mental Hx: Diagnosis of Anxiety and depression. No history of self-harm practices and/or suicidal or homicidal ideation ever.
Reproductive Hx: patient reported she prefers male partners. She reported she has only one sexual partner, and she is sexually active. The patient reports she has never been pregnant, LMP is 08-23-2022.
GENERAL: patient reported no recent weight loss, fever/chills, weakness, or fatigue.
HEENT: Eyes: No visual loss or double vision. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: skin is dry with no rash or itching.
CARDIOVASCULAR: No chest pain or chest discomfort. No palpitations.
RESPIRATORY: No shortness of breath and no cough.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea.
NEUROLOGICAL: No headache, dizziness, syncope, or paralysis. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, joint pain, or stiffness. Active in all extremities.
HEMATOLOGIC: No bleeding or bruising.
LYMPHATICS: No enlarged nodes or history of splenectomy.
PSYCHIATRIC: positive history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. Mild sweating in the palms due to anxiety.
GENITOURINARY/REPRODUCTIVE: Burning on urination. LMP: 08/23/2022. Watery yellow discharges in large amounts.
ALLERGIES: No known allergies.
Physical exam: General: V/S include; Height-5 5,?Weight?-148?(BMI 24.6),?BP-132/68, P-62, R-22, T-98.6, O2- 98% RA. Patient in no physical distress, alert, and oriented to person, place, time, and situation.
Head/ Neck: Normocephalic and atraumatic. Lymph nodes are grossly normal.
EENT: Denies vision loss, hearing loss, nasal congestion and/or discharges, and sore throat.
Lungs/CV: Chest is clear to auscultation bilaterally, normal respiration, rhythm, and depth upon exam. Denies palpitations and chest pain.
GI: Denies nausea, vomiting, diarrhea, and anorexia.
Musculoskeletal: Active in all extremities with a steady gait.
GU: Patient is positive for burning sensation when urinating and denies frequent urination. Positive for yellow watery vaginal discharges with a strong smell. Positive for lower abdominal pain on palpation, cervix firm and smooth. The uterus is mobile and non-tender. The breast exam is normal on palpation, and no nodules were noted.
Psych: Patient is moderately anxious, has mild sweating, and respirations of 22. Able to comprehend and narrate history.
Diagnostic results: Include nucleic acid amplification tests (NAATs), which include vaginal swabs collection, urine analysis, and culture. Test results were positive for Chlamydia, it was detected in the swab and the urine samples.
Primary and Differential Diagnoses; Primary is Chlamydia
Cervicitis: inflammation of the cervix usually caused by infection, exposure to chemical exposure, or the presence of a foreign body. Symptoms include; unusual vaginal discharges, painful sex, painful urination, abnormal vaginal bleeding, and pressure in the pelvis.
Pelvic Inflammatory Disease: an infection of the female reproductive organs due to the spread of sexually transmissible bacteria from the vagina to the uterus, fallopian tubes and ovaries. Symptoms include pelvic pain, fever, vaginal discharges, painful menstruation, nausea/vomiting, and lower abdomen/back pain.
Gonorrhea: A venereal disease involving inflammatory discharge from the urethra and vagina, it is caused by a sexually transmissible bacteria, and symptoms include; pain in the lower abdomen/back, painful urination, and vaginal discharges.
Doxycycline 100 mg PO twice daily for seven days.
Azithromycin 1g once by mouth day 1, followed by 500mg once daily for 2 days.
Ibuprofen 600 mg PO as needed.
Chlamydia is an STI that can cause permanent damage to a womans reproductive system if not properly treated, causing the impossibility of getting pregnant at a later age. Chlamydia can cause potentially fatal ectopic pregnancy.
Conclusively, I agree with the treatment regimen above, as it is the first-line treatment recommended by CDC for this infection, Davidson et al., 2021.
A sexually transmitted disease case report was completed and returned to the Department of Health post diagnosis of chlamydia as recommended by the state.
Patient education is given to the patient on screening for HPV and other STIs and prevention. The patient was also educated on the disease chlamydia and its long-term effects, and how it can be prevented.
Follow-up scheduled in one month with the Gynecologist. If there is any reaction to the prescribed medications, the patient should reach out to the clinic as soon as possible. The patient was informed about the treatment of her partner if has not started treatment yet.
Additional questions asked to the patient include:
Can you tell if your boyfriend has another partner?
Do you practice oral and anal sex?
Can you explain how this entire situation affects your everyday activities
What do understand by venereal diseases or sexually transmitted diseases?
Davidson, K. W., Barry, M. J., Mangione, C. M., Cabana, M., Caughey, A. B., Davis, E. M., … & US Preventive Services Task Force. (2021). Screening for Chlamydia and Gonorrhea: US preventive services task force recommendation statement. JAMA, 326(10), 949-956.
Frej-M?drzak, M., Grybo?, A., Grybo?, M., Teryks-Wo?yniec, D., Jama-Kmiecik, A., Sarowska, J., & Choroszy-Król, I. (2018). PCR diagnostics of Chlamydia trachomatis in asymptomatic infection by women. Ginekologia Polska, 89(3), 115-119.
Hammerschlag, M. R., & Sharma, R. (2021). Azithromycin in the treatment of rectogenital Chlamydia trachomatis infections: end of an era?. Expert Review of Anti-infective Therapy, 19(4), 487-493.
Huai, P., Li, F., Chu, T., Liu, D., Liu, J., & Zhang, F. (2020). Prevalence of genital Chlamydia trachomatis infection in the general population: a meta-analysis. BMC infectious diseases, 20(1), 1-8.
Kong, F. Y. S., Tabrizi, S. N., Law, M., Vodstrcil, L. A., Chen, M., Fairley, C. K., … & Hocking, J. S. (2014). Azithromycin versus doxycycline for the treatment of genital chlamydia infection: a meta-analysis of randomized controlled trials. Clinical Infectious Diseases, 59(2), 193-205.