soap note for one of the STDs

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Patient particulars

Initials: J.P

Age: 39years

Gender: Female

Ethnicity: American

Subjective Data

Chief complaint: lower abdominal pain for two weeks

History of presenting complaint: J.P is a 39years old American female presenting at the emergency department with lower abdominal pain. the pain is of gradual onset because it was initially a mild discomfort and progressively severe over the days. The pain is worse on exertion and after voiding. Relieving factors are resting and taking Tylenol. The pain is dull and radiates to the back and the flank region. Other associating symptoms are vaginal discharge that is foul-smelling and copious in amount. The patient reports vulval itchiness, dyspareunia, dysuria, chills, rigors, and fatigue.

Past medical history: the patient has had a history of seasonal allergic rhinitis since childhood. She has had hypertension and diabetes for one year. She was hospitalized three years ago due to chronic pyelonephritis and chlamydia infection. She denies blood transfusion.

Past surgical history: the patient has undergone two cesarian sections when giving birth to her two children. She has a history of anal wart sclerotherapy three years ago. She has a history of a marsupialization of a Bartholin cyst two years ago.

Current medication: HCTZ 25mg PO once daily for hypertension. Metformin 500mg PO twice daily for diabetes. Loratadine 10mg PO PRN for seasonal allergic rhinitis.

Allergies: the patient is allergic to pollen, animal fur, and dust. She develops a cough, sneezing, running nose, and body itchiness. She relieves these symptoms by avoiding the allergen and taking loratadine. She denies food, drug, and latex allergy.

Immunization: her childhood immunization schedule is up to date. Her last tetanus and influenza vaccine were three months ago. She denies uptake of the human papillomavirus vaccine.

Health maintenance history: the patient visits the hospital for regular blood pressure and glucose monitoring. She denies annual optical, dental, mammogram, and pap smear check-ups. She has smoke detectors in her house. She uses a seat belt when in the car. She does not use her phone when walking along the roadside and when driving.

Social history: J.P is a single lady with two children from her two previous relationships. She is a grade six drop out due to financial constraints from her background. She works as a salesperson and waitress in a local bar. She enjoys hanging around with her friends drinking whisky, smoking cigarettes and tobacco, and gambling. She prefers taking take-out meals like fried food, soda, coffee, and bread.

Family history: she is the firstborn in a family of three. Her father is 65years old and living with hypertension and diabetes mellitus. Her mother passed on two years ago due to stage four cervical cancer. She had hyperlipidemia, hypertension, and asthma. Her younger sister is 35years old with obesity and diabetes. Her younger brother 30years old has alcohol withdrawal symptoms.

Sexual and reproductive health history: her menarche was at the age of 16years old. She has had a regular 28days cycle with four days of moderate flow. She has a positive history of dysmenorrhea. Her last menstrual period was 26/7/2022. She has been using emergency contraception pills as her contraception method during her fertile days in the cycle. She denies contraceptive-related complications. She has two children, a 12years old daughter, and 8years old son. They were born at term via the cesarian section. She denies pregnancy-related complications and post-partum diseases. Her first sexual encounter was at the age of 18 years. She is heterosexual and has had multiple sexual partners since then. She engages in oral, anal, and vaginal sexual intercourse. She denies the use of condoms and screening for sexually transmitted diseases in her sexual partners. She has a positive history of recurrent urinary tract infections and sexually transmitted diseases.

Review of system

General: the patient has a fever, fatigue, and chills. She denies weight loss and night sweats.

HEENT:  The patient denies headache, dizziness, blurring of vision, eye pain, loss of hearing, ear pain, throat pain, runny nose, nasal congestion, and neck pain.

Respiratory system: the patient denies coughing, chest pain, wheezing, shortness of breath, and sputum production.

Cardiovascular system: the patient denies palpitations, orthopnea, paroxysmal nocturnal dyspnea, tachycardia, and lower limb swelling.

Gastrointestinal system: the patient denies abdominal pain, reflux, heartburn, nausea, vomiting, diarrhea, and constipation.

Musculoskeletal system: the patient denies joint pain, muscle spasms, stiffness, and swelling of the joints

Neurological system: she denies numbness of extremities, muscle weakness, facial droop, and tingling sensation.

Hematological system: she denies bleeding tendencies, anemia, recurrent infections, and fainting episodes.

Endocrine system: she denies heat and cold intolerance, irritability, striae, and fatigue.

Integumentary system: the patient denies acne, skin rash, and alopecia.

Psychiatry: the patient denies anxiety, depressive mood, bizarre behavior, psychosis, and hyperactivity.

Objective Data

General: the patient is calm and alert. She is sitting upright at the interview desk. She has no pallor, jaundice, cyanosis, edema, dehydration, or lymphadenopathy.

HEENT: the head is round with no swelling or signs of trauma. The eyes have a normal size and shape bilaterally. The conjunctiva is pink and the sclera is white. The eustachian tube is shiny and without discharge. There are no post nasal drip and nasal polyps. The mouth is moist with no erythema, oral sores, and erythematous pharyngeal glands.

Genitourinary system: the patient has a distended supra-pubic region. There is tenderness at the suprapubic and bilateral flanks. There is cervical motion tenderness. The external genitalia has a normal size and shape. She has a vaginal discharge green in color, mucopurulent, and foul smelling. The vaginal walls are edematous and erythematous with sores. The labial Majora has non-tender-like skin tags that spread to the perineum.

Respiratory system: the chest has no scars, mass, and therapeutic marks. The vocal fremitus is symmetrical. There is a resonant percussion note and the vesicular breath sounds. There is no wheezing, rhonchi, or crackles.

Cardiovascular system: the heart sounds s1 and s1 are present at a regular rate and rhythm without murmurs. The peripheral pulses are present without bruits. There are no parasternal heaves and thrills.

Gastrointestinal system: the abdomen is round without flank fullness. The bowel sounds are present. The liver span is 1cm below the coastal margin, there is no mass, and there is no organ enlargement. There are no fluid thrills and shifting dullness.

Musculoskeletal system: the patient has no bone deformities and fractures. He maintains an upright and steady gait.

Mental state examination: the patient is alert and oriented to time, place, and person. She is in a happy mood and has a broad affect. Her speech is lough audible, clear, and coherent. Her thought process is future-oriented. her judgment and insight are intact. She denies hallucinations and suicidal ideations.

Assessment

Differential diagnoses

1. Gonorrhea A54.9
2. Human papilloma virus R87.81
3. Vaginitis N77.1

Primary diagnosis: gonorrhea is a bacterial infection of the mucous membrane. It is transmitted through sexual intercourse or childbirth. The causative organism is gram-negative diplococcus Neisseria gonorrhea. The common sites of infection with Neisseria gonorrhea are the endocervix, eyes, and the urethra. The presenting symptoms are vaginal discharge, dysuria, lower abdominal pain, dyspareunia, fever, chills, rigors, nausea, and vomiting (Hook III, E. W., & Kirkcaldy, R. D. 2018). On examination, the patient has cervical motion tenderness, adnexal tenderness, and mucopurulent discharge. Risk factors for gonorrhea are unprotected sexual intercourse, multiple sexual partners, low socio-economic status, history of concurrent sexually transmitted diseases, exchanges of sex for money or drugs, and early age of sexual activity. This is the primary diagnosis because the patient presents with similar symptoms, has multiple sexual partners, does not use protection, and has a history of other sexually transmitted infections.

The human papillomavirus is a sexually transmitted infection whose manifestation is at the epithelium and mucous membranes. It presents with keratotic warts at the labia majora and perineum. They are asymptomatic and their diagnosis is often missed. A patient with HPV has no symptoms unless there is a co-infection with chlamydia and gonorrhea infection (Wang, et al, 20180. This patient presents with genital warts and she has a positive history of sclerotherapy of anal warts.

Vaginitis is the inflammation of the vaginal mucosa caused by bacterial or fungal infections like trichomoniasis. It presents with vaginal discharge, milky discharge, and irritation of the vulva region (Neal, et al, 2020). Causes are hormonal changes, poor hygiene, sexual activity, and advancing age. Sexual activity with a new partner alters the normal vaginal PH hence destroying the normal flora. Sexual activity with a partner with sexually transmitted diseases increases the risk for vaginitis.

Plan

Diagnostic tests

The patient has a positive family history of cervical cancer and has anogenital warts. Therefore, I would recommend a pap smear test, HPV DNA testing, and acetic testing to screen for cervical neoplasia. Urinalysis helps rule out urinary tract infections. A high vaginal swab for microscopy and culture helps determine the causative agent for the infection. Pelvic ultrasound to rule out other pelvic diseases and pelvic mass.

Pharmacological treatment

1. Tylenol 1g PO TDS for pain and fever
2. Azithromycin 500mg PO once daily and doxycycline 100mg PO twice daily for 10 days for gonorrhea.
3. Continue with HCTZ and metformin for hypertension and diabetes mellitus.

Patient Education

1. Train of hygienic measures of the vaginal such as washing inner clothing and sexual hygiene
2. Use protection when engaging in sexual intercourse to prevent contracting diseases and spreading HPV.
3. The patient should abstain from sex until recovery
4. She should regularly go for a pap smear and colposcopy for early diagnosis and treatment of cervical cancer.

 

References

Hook III, E. W., & Kirkcaldy, R. D. (2018). A brief history of evolving diagnostics and therapy for gonorrhea: lessons learned. Clinical Infectious Diseases, 67(8), 1294-1299. https://doi.org/10.1093/cid/ciy271

Neal, C. M., Kus, L. H., Eckert, L. O., & Peipert, J. F. (2020). Noncandidal vaginitis: a comprehensive approach to diagnosis and management. American journal of obstetrics and gynecology, 222(2), 114-122. https://doi.org/10.1016/j.ajog.2019.09.001

Wang, R., Pan, W., Jin, L., Huang, W., Li, Y., Wu, D., … & Liao, S. (2020). Human papillomavirus vaccine against cervical cancer: Opportunity and challenge. Cancer letters, 471, 88-102. https://doi.org/10.1016/j.canlet.2019.11.039