SOAP NOTE ON CHLAMYDIA

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Race/Ethnicity: Caucasian

Occupation: Personal Assistant

Admission Date:

Chief Complaint: The patient presented burning sensation on urination, yellowish per vaginal discharge, lower abdominal pain, and pain during sexual intercourse.

HPI: The patient is a healthy, young 25-year-old Caucasian female who was well until one week ago when her complaints started. She began experiencing a burning sensation while urinating associated with lower abdominal pain. Cramping radiating to the lower back worse while urinating. She has also seen yellowish vaginal discharge with foul smell after sexual intercourse. The body has been hot from time to time (Kovachev, 2014). These complaints started after having unprotected sex. The last menstruation occurred two weeks ago, which was normal for her. She began having her menses at the age of twelve, non-parous on oral contraceptives.

Past Medical History (PMH)

  • Current Medication: Currently on oral contraceptives.
    Allergies: The patient is allergic to peanuts causing hives and airway swelling. Season changes may cause a runny nose and watery eyes.
  • Immunization Status: The patient is up to date on all her vaccines. A possible FLU shot vaccine and HPV vaccine to be offered today.
  • Previous Tests: Normal Pap smear test. HIV test was negative.
  • Childhood Illness: The patient suffered from chicken pox at the age of 7.
  • Major illness as an adult: None
  • Injuries: The patient broke her hand on the school field at the age of 10.
  • Surgeries: N/A

Family history

The patient’s mother has a history of diabetes type one diagnosed at the age of 46. Her mother has been using insulin treatment. Since she detected it early, she is currently doing fine. The patient claims of no other family medical history.

Social History

The patient is a personal assistant to the CEO at Blackstone International and perusing her master’s degree. She eats healthy and exercises daily. Uses alcohol on weekends, smokes a packet of cigarettes daily. She had multiple sexual partners in the past.

ROS

General: Clinically febrile, Unusual fatigue, no recent weight loss or gain, no night sweating, no loss of appetite, no sleep disturbance.

HEENT: Nose, Ears Mouth, and Throat: Morning headaches, no vertigo, dental problems, nasal congestion, epistaxis, hoarseness, oral lesions, sinus problems. Eyes: patient denies difficulty in focusing, diplopia, blurred visions, and peripheral visual change.

NECK: Denies the feeling of swollen lymph nodes, goiter or pain to the neck

BREAST: Denies lumps, pain or discharge, performs own self-breasts exams monthly and denies any discolorations on the skin.

RESPITORY: Denies coughing, wheezing, and difficulty in breathing during normal weather.

CARDIOVASCULAR: Denies any chest pain, palpitations, syncope or irregular heart rate. Reports no dyspnea, edema. Reports no echocardiogram performed.  

NEURO: Reports no seizure or weakness. Denies fainting, blackouts, seizures. Reports no vertigo and denies any paralysis.

OBJECTIVE

Vitals: BP-110/66, Temp-98.8, HR-67, Height-5’6’, Weight-179 Ibs. General appearance: the patient appears to be healthy, well developed, and nourished. No obvious distress level, Ambulation; Normal gait.

Eyes: PERRLA, no ptosis, Light reflex present both direct and consensual. No retinal lesions or hemorrhages. No orbital edema.

Ears: EAC's clear. TM no erythematous, bulging or dullness. External auditory canal intact without deformities.

Nose: No edematous turbinate’s, clear rhinorrhea. No nasal tenderness.

Throat: Clear, no exudates, no lesions. No odor to the breath. Uvula midline with no tonsil enlargement.

NECK: Trachea midline, no tenderness to thyroid, no bruits heard to carotids. No enlarged lymph nodes palpated.

BREAST/NODES: No masses, enlargement, or discharge to the nipple. Skin intact. No swollen axillary nodes. 

GENITOURINARY: No dissertations noted, external genitalia looks normal, no gross lesions or laceration, on spectrum examination vaginal mucosal membrane visible pink and healthy, yellowish. White discharge noted cervix closed, hyperemic, friable with visible yellowish discharge. A higher vaginal swab was taken for a wet prep and pap smear.

PER ABDOMEN EXAMINATION: normal abdomen, moving respiration, mild suprapubic tenderness.

BIMANUAL EXAMINATION: motion tenderness active, blood stained yellowish foul smelling per vaginal discharge on the testing finger.

NEUROLOGICAL: The patient's communication is standard, attention and concentration average, the patient's sensation of gait and light is normal.

CARDIOVASCULAR: No murmurs, gallops or rubs, S1, S2 regular rate, and rhythm.

IMMUNOLOGICAL: No bruising or bleeding, no tenderness or masses present, lymph nodes not palpable.

Assessment

Vaginitis/cervicitis r/o chlamydia, urinary tract infection.

Plan

LAB TEST

Wet prep: chlamydia tracheitis is seen.

Pap smear: normal

Urinalysis: normal

HIV test: negative.

Pregnancy test: negative.

Treatment

P. O Tab Azithromycin 1gm stat

P. O Tab Levofloxacin 500mg od * 1/52

P. O Tab brufen 400mg TDS x 5/7

Counsel and provide condoms for prevention of the disease transmission.

Advise sexual partner also to get treatment.

Reflection

I have learned that multiple sexual partners or a new sexual partner are a predisposition to chlamydia infection. Sexual intercourse often increases sexually transmitted disease infection chances. Excessive consumption of alcohol also increases the likelihood of infection. Early diagnosis of the infection has 95% response to antibiotic treatment with a very low resistance to first line treatment. Lack of treatment can cause pelvic inflammatory infection with an increase in tubal factor infertility.

Patient Education

If a dose is missed, take one pill as soon as possible. Oral contraceptives (OCs) do not prevent STDs or HIV/AIDS.

Oral contraceptives can cause DVTs; avoid smoking since it increases the chances (Lambert, 2014). Using condoms prevents some sexually transmitted diseases. Using condoms as a preventive measure is significant.

 

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