Complete all the requirements of the case scenario.
Use at least one scholarly source
PLEASE USE THE TEMPLATE BELOW FOR THE SOAP NOTE SECTION
Demographic Data
Age and gender (must be HIPAA compliant)
Subjective
Chief Complaint (CC): A short statement about why they are there
History of Present Illness (HPI): Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment
Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance
Family Hx: any history of CA, DM, HTN, MI, CVA?
Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
Objective
Vital Signs
Physical findings listed by body systems, not paragraph form- Highlight abnormal findings
Assessment (the diagnosis)
At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each
Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation
Plan
Dx Plan (lab, x-ray)
Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)
Pt. Education, including specific medication teaching points
Referral/Follow-up
Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due
Case Scenario 1
Table 1
Infection
Description Presentation Causes/
Risk
Factors
Candida
BV
Chlamydia
Gonorrhea
Trichomonas
Cervicitis
PID
HIV
Syphilis
Hep B
Hep C
HSV
Table 2
Question
Name 10 Risk Factors for contracting
STIs and HIV
Name 5 safer sex practices
Can HIV be transmitted through sweat,
saliva, and tears? (Include rationale)
Name 2 types of intercourse are at the
highest risk for contracting HIV
Why are women more susceptible to
HIV in a male to female relationship
Answer
Treatment Addtl
per CDC
info
(versus a male contracting it from a
female)?
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. Lisas 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.
1. Subjective:
a. What other relevant questions should you ask regarding the HPI?
b. What other medical history questions should you ask?
c. What other social history questions should you ask?
2. Objective:
a. Explain what POCT will you order and perform, and discuss your
rationale for ordering and performing each test.
3. Assessment/ Diagnosis:
a. What would be an appropriate diagnosis for her? Why?
b. Any other diagnosis or differential diagnosis you would like to add?
4. Plan:
a. 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
b. 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.
c. What patient education is important to include for this patient?
(Consider when can the patient resume sexual activity)
d. Explain complications that can occur if patient does not comply with treatment regimen.
Recent Comments