I Need two Responses Per Each Soap Note Discussion Total 8 Responses. Posts Will Be A Minimum Of 100 Words, APA Format.One Reference Per Each Discussion

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PATIENT INFORMATION:

NAME: A.R.

SEX: Female.

AGE: 28 y/o

ALLERGIES: Latex.

IMMUNIZATION STATUS: Up to date

PREVIOUS SCREENING TESTS RESULT: Negative Pap smear in 09/26/2019, no history of abnormal pap results.

PRIOR HOSPITALIZATIONS: No hospitalizations.

CURRENT MEDICATIONS: none.

PAST MEDICAL HISTORY: Unremarkable

OB AND GYN HISTORY:

Menarche: 11 years old

Lent of cycle: 28 days/4-5 days, regular.

L.M.P: 08/20/2020 normal bleeding.

Pregnancy history: G1, T0, P0, A1 (spontaneous abortion 20017), L0

History of STIs: None

No history of abnormal pap result

Sexual history: active, refers only one partner now. Heterosexual.

Contraceptive use: norethindrone-ethinyl estradiol, one pill every day

SURGICAL HISTORY: unremarkable.

GYN PROBLEMS/PROCEDURES: None

FAMHX: Mother alive (Migraine).

SOCIAL HISTORY: The patient was born in Cuba, never married, studied and working now, she’s not smoker, no used alcohol or illegal drugs. Refers she drink coffee 2-3 times per day.

SUBJECTIVE:

CC: “I’m having yellow vaginal discharge and strong smelly”.

HPI: A 28-year, female, Hispanic race, come to our medical office reporting she having three days with yellow vaginal discharge with a strong smell, accompanied whit pain in the lower abdomen, and she refers used unprotected sex in the last month different times with her new boyfriend, she denies having fever, back pain, urinary symptoms, denies nausea, no vomiting, no abnormal vaginal bleeding between periods. Her last past menstrual period was 3 weeks ago. Denies any past medical condition.

ROS:

CONSTITUTIONAL: Patient denies chills, fever, weight loss, diminished appetite, unusual thirsty, but has had unexpected generalized weakness for the last month.

HEENT: Eyes- Denies diplopia, eye pain, blurred vision, redness, or flashing lights. No use corrective lenses or glasses. Ears, nose, mouth, and throat- Patient denies vertigo, headaches, sinus problems, epistaxis, hoarseness, dental problems, oral lesions, hearing loss or changes, nasal congestion.

CARDIOVASCULAR: Denies chest pain, palpitations, dizziness or fatigue.

RESPIRATORY: Denies shortness of breath, denies cough, congestion or production of

sputum

GASTROINTESTINAL: Denies abdominal pain, no history of abdominal surgery, also

denies rectal bleeding and constipation, no diarrhea.

GENITOURINARY: Denies burning sensation, no frequency urination. No back pain, no nocturia. No medical history conditions.

GYNECOLOGICAL: No vaginal bleeding. no intermenstrual bleeding, or postictal bleeding, refers having three days with yellow vaginal discharge with a strong smell, accompanied whit pain in the lower abdomen, and she refers used unprotected sex in the last month different times with her new boyfriend pain with intercourse (dyspareunia). Denies medical history of STD.

MUSCULOSKELETAL: Denies muscle weakness or spasms, muscle or joint pain.

SKIN: Denies recent rash or unexpected onset of skin lesions.

NEUROLOGIC: Denies tremors, headache, seizures, mild gait imbalance due to leg pain tics or numbness in lower extremities, no visual disturbances or speech problems, no dizziness.

OBJECTIVE:

PHYSICAL EXAMINATION:

GENERAL: Healthy-appearing, well-nourished, and well-developed. Alert in no distress, and cooperative. Normal gait, no weigh loss or gain.

Vital Signs:

BMI: 24.5 kg/m2

Blood Pressure 110/72 mm hg

Pulse: 90 P/min,

Respiration rate:18 breaths /min.

Weight:152 pns.

Height: 5'6''

Temperature 97.9 oF.

SpO2: 98 % on room air.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Eyes: Sclera white,

conjunctiva pink, no icterus, excessive tearing, or exudate, no edema or lesions noted. PERRLA. Visual acuity and extraocular eye movements intact. Ears: Bilateral canals patent and non-tender, but with marked erythema. No edema, lesion, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Throat: Posterior oropharynx normal; uvula midline. Mucous membranes pink, moist, without ulceration.

CARDIOVASCULAR: No jugular venous distention, regular heart rate and rhythm without murmurs, rubs, or gallops, there is no chest wall tenderness on unaffected side, no collateral circulation, no carotid murmur bilaterally.

RESPIRATORY: The patient is speaking in full sentences, no dyspnea or use of accessory muscle, no dullness to percussion, or increased tactile fremitus over the lung fields has no cyanosis, rhonchi or crackles noted, vesicular murmur present bilaterally.

GASTROINTESTINAL: Oral cavity with no lesions suggestive of malignancy, wet oral mucosa, abdomen soft, non-tender, non-distended, no abdominal scars, no organomegaly, no hernias, bowel sounds present in all four quadrants

GENITOURINARY: Percussion over CVA elicits no pain.

GYNECOLOGICAL: Speculum examination: normal distribution and amount of pubic hair, no external genitalia lesions, no ulcerations, yellow mucoid cervical discharge; friable appearance of the cervix; and cervical motion tenderness.

MUSCULOSKELETAL: Denies muscle weakness or spasms, muscle or joint pain.

INTEGUMENTARY: Pink, warm, no rash, no nevi suspected as malignant, no macules, papules or vesicles, no other skin impairment.

NEUROLOGIC: AAOx3, no gait disturbances, no central or peripheral focal neurological deficit, muscle tone, grip strength and gross sensation, intact.

ASSESSMENT:

Chlamydial Infection of Genitourinary Tract, Unspecified (ICD10 A56.2): Could be asymptomatic or be present with Abnormal vaginal discharge that may have an odor, bleeding between periods, Painful periods, dyspareunia, Itching or burning around the vagina, pain when urinating. Cause pelvic inflammatory disease, Cervicitis, endometritis, salpingitis (Black, 2013). This patient come to the medical office after three days with yellow vaginal discharge with a strong smell, accompanied whit pain in the lower abdomen, and refer unprotected sex in the last month.

Other Diagnosis:

ICD 10: Z72.51; High risk heterosexual behavior.

Differential Diagnosis:

Gonococcal vulvovaginitis, unspecified (ICD10 A54.02): Discharge from the vagina (watery, creamy, or slightly green). Pain or burning sensation while urinating. Cause pelvic inflammatory disease. (Skolnik, Clouse, & Woodward, 2013).

Trichomonal vulvovaginitis (ICD10 A59.01): vaginal discharge, which can be white, gray, yellow, or green, and usually frothy with an unpleasant smell, vaginal spotting or bleeding, genital burning or itching, genital redness or swelling, frequent urge to urinate, pain during urination or sexual intercourse. Strawberry vagina during physical examination. (Codina Leik, T. M. (2017).)

Candidiasis of vulva and vagina (ICD10 B37.3): white vagina discharge, erythematous cervix, cover with white exudate, no odor, no bleeding, no purulent exudate or ulceration in the

vulvovaginal area or cervix. Reddened and swollen vulvar and vaginal tissues. (Codina Leik, T. M. (2017).

PLAN:

Laboratory exam:

Vaginal exudate, Neisseria gonorrheae test; chlamydia test. KOH.

Urinalysis.

STD panel

PHARMACOLOGIC TREATMENT:

Azithromycin: 1 g orally as a single dose .

Treatment to Sexual Partners: Administer azithromycin 1 g PO in a single dose.

Education:

Swallow with large amount of water; may cause esophagitis if tablet gets stuck in throat

(difficulty and/or pain with swallowing, acute-onset heartburn, nausea/vomiting), Nausea, GI upset, photosensitivity (avoid sun or use sunscreen)

Effective clinical management of patients with treatable sexually transmitted diseases (STDs) requires treatment of the patients’ current sex partners to prevent reinfection and curtail further transmission Don’t have sex during the treatment time. You can get chlamydia if you’re exposed again, even if you’ve treated a previous infection.

The surest way for a sexually active person to avoid contracting chlamydia is to use a condom during sexual intercourse, unless you’re absolutely certain your partner isn’t carrying the infection. You should either avoid having oral sex, or use protection during oral sex, until you know the other person doesn’t have chlamydia. Use protection with each new partner and get tested for chlamydia and other sexually transmitted diseases between each new partner.

FOLLOW-UPS/REFERRALS:

Follow up in 7 days to review lab studies results.

Referral: No.

REFERENCES:

Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2017. September 2018

Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015 Jun 5;64(RR- 03):1-137.

American Congress of Obstetricians and Gynecologists. Committee opinion no. 506: expedited partner therapy in the management of gonorrhea and chlamydia by obstetrician-gynecologists. Obstet Gynecol. 2015 Sep;118(3):761-6

Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015 Jun 5;64(RR- 03):1-137.

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