Focused SOAP Note Template Of Gonorrhea Diagnosis

Focused SOAP Note Template Of Gonorrhea Diagnosis

Patient Information

Ms. R.S. aged 23 is an African American woman

Onset: About a month ago

Character: history of excess creamy, white discharge

Associated signs and symptoms: Itching sensation, burning, intermittent pelvic pain around the bladder

Timing: Since about one month

Exacerbating/relieving factors: sexual intercourse is painful, vaginal discharge is consistent

Severity: 8/10 pain while urinating

Current Medications: Tylenol prn

Allergies: No known allergies

PMHx: R.S. was born with a low birth weight and weighed less than 5 pounds. During her childhood, R.S. was smaller than other children of the same age. She frequently had intermittent fever with cold and used supplements to maintain a normal healthy weight. Focused SOAP Note Template Of Gonorrhea Diagnosis

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Soc & Substance Hx: R.S. passed high school 5 years ago and after that she attended community college where she obtained a degree in marine biology. She currently works as a marine biologist at the marine research institute. She is a party- holic and enjoys to visit the night clubs and pubs after work or on her days off. Her mother was a single mom who died when R.S. was 12. R.S. was however very close to her two siblings.

R.S. lives alone and does not have any children. She has had two abortions, one at the age of 15 during high school and another at 21. She has not been pregnant after this. She has been dating someone who wants to have a child with R.S. to further strengthen their relationship.

Fam Hx: R.S.’s mother was hypertensive and died at age 52. Her siblings are healthy without any known medical complications. History of R.S.’s father is unknown. Her maternal grandfather is alive and is 74 years old. He has been diagnosed with COPD and is active drinker, and smoker.

Surgical Hx: During the age of 8, R.S. was involved in a motor accident which fractured her femur that was repaired through a surgical procedure. She was in the hospital for three weeks during that time and in rehabilitation for four months.

Mental Hx: R.S. does not have any known mental health concerns.

Violence Hx: R.S. does not have history of violence.

Reproductive Hx: LMP- 23^rd February, 2022, pregnant – no, nursing/lactating- no, contraceptive used- latex condom, performed oral, and vaginal intercourse last week, has been observing creamy discharge with a distinct odor and sexual intercourse has been painful for her Focused SOAP Note Template Of Gonorrhea Diagnosis

General: No weight loss, fever, chills, weakness, or fatigue.

Heent: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

Medical History

SKIN: No rash or itching.

Cardiovascular: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

Respiratory: No shortness of breath, wheezing, cough, or sputum.

Gastrointestinal: No Anorexia, Nausea, Vomiting, Or Diarrhea. No Abdominal Pain Or Blood.

Genitourinary: Burning On Urination, Itching And Pain In Pelvic Area. Lmp: 02/23/2022.

Neurological: No Headache, Dizziness, Syncope, Paralysis, Ataxia, Numbness, Or Tingling In The Extremities. No Change In Bowel Or Bladder Control.

Musculoskeletal: No Muscle Pain, Back Pain, Joint Pain, Or Stiffness.

Hematologic: No Anemia, Bleeding, Or Bruising.

Lymphatics: No Enlarged Nodes. No History Of Splenectomy.

Psychiatric: No History Of Depression Or Anxiety.

Endocrinologic: No Reports Of Sweating Or Cold Or Heat Intolerance. No Polyuria Or Polydipsia. No Report Of Irregularity In Menstrual Flow.

Reproductive: Not Pregnant And No Recent Pregnancy. No Reports Of Vaginal Or Penile Discharge. Not Sexually Active. Focused SOAP Note Template Of Gonorrhea Diagnosis

Allergies: No history of asthma, hives, eczema, or rhinitis.

Generally: R.S. appears well nourished and is orientated to time, place, and date. Shows normal effect and mood, and is ambulating without difficulty.

Head- Normocephalic, symmetrical face, negative for abnormal protrusions, hair distributed normally

Eyes- Sclera is white, conjunctiva is moist, clear, and smooth without any drainage, EOM and visual field is intact

Ears- TM is pearly gray, and clear, cone of light is noted and appropriately distributed, Ears negative for redness, pus, drainage, or foreign bodies

Nose- Nares present, septum is midlines, nasal mucosa pink and moist, negative for polyps, drainage, selling or sinus tenderness

Teeth/gums-No obvious caries or periodontal disease. No gingival inflammation

Mouth- tongue is moist and pink, negative for dryness, oral mucosa is pink and moist, negative for ulcers, bleeding, swelling or lesions

Throat- uvula midline non- bifurcated, no inflammation of tonsils, palate intact, no carries, no pain

Cardiac: Regular heart rate and rhythm with no murmurs; normal S1 and S2. No S3, S4 murmurs detected. No peripheral edema, pallor, or cyanosis. Warm extremities that is fully perfused with capillary refill less than 2 seconds.

Respiratory: Normal respirations were normal and regular. Symmetrical chest expansion with clear bilaterally auscultation. Rhonchi, rales, diminished breath sounds or wheezing were not observed Focused SOAP Note Template Of Gonorrhea Diagnosis.

Abdominal: Abdomen appeared soft, non-tender, non-distended throughout the palpation. No masses felt, spleen size normal, uterus not palpable and bowel sounds positive. G/U: Presence of discharge noted.

Neuro: Gait is normal. R.S is fully mobile and oriented to time and place.

Gonorrhea- Gonorrhea is a STD, the causative agent of which is Neisseria gonorrheae. Clinical characteristics of gonorrhea include creamy white discharge, pain in pelvic area accompanied with burning and itching. This infection in females can remain asymptomatic until a more severe pelvic condition emerges. This diagnosis is considered to be the primary diagnosis because R.V. is sexually active. She is a young female who has had many sexual partners in the past which puts her at an increased risk of acquiring gonorrhea. She also complained of a persistent, creamy, white discharge. R.S. was also positive for NAAT (nucleic acid amplification test), making gonorrhea the most likely diagnosis (Hook III & Kirkcaldy, 2018).

Social History

Pelvic inflammatory disease (PID)-PID is a disorder that affects only females making it a likely diagnosis for R.S. since she was also experiencing clinical characteristics of PID which includes pelvic pain, vaginal discharge associated with unpleasant odor, and pain during sexual intercourse. PID is usually caused by a bacterial infection that develops first in the vagina or the cervix and progresses into womb, ovaries, and the fallopian tubes. Incomplete abortions, and using intrauterine devices can precipitate this infection (Curry, Williams & Penny, 2019)Focused SOAP Note Template Of Gonorrhea Diagnosis.

Chlamydia trachomatis infection- This pathogen is an obligate intracellular pathogen that attacks human. It infects the human genitalia. The organism is gram negative and is associated with symptoms such as creamy and white vaginal discharge, along with dysuria, pain in the lower abdomen, and burning sensation while urinating. During the latent stage the organism is transmitted via sexual intercourse and the symptoms later develop in the infected person. Chlamydia infection is very similar to gonorrhea making this the second most likely differential diagnosis, however in case of a chlamydia infection, the vaginal discharge of a woman appears yellowish and is associated with a strong odor. Green discharge also commonly occurs in woman (Lausen, Christiansen, Poulsen & Birkelund, 2019).

Herpes- Herpes is the third most likely diagnosis for R.S. Herpes is a genital infection, the causative agent of which is herpes simplex virus (HSV-1 and HSV-2). This condition is presented as eruptions on the surface of the vestibule or the labia which are painful and also irritate the skin. Herpes is associated with small or tiny red or white bumps and blisters, formation of ulcers that upon rupturing ooze and bleed, scabs, and pain and itching (Cole, 2020)Focused SOAP Note Template Of Gonorrhea Diagnosis. This is the third likely diagnosis for R.S because although she was experiencing pelvic pain and discharge but she did not present with bumps or blisters, ulcers, or scabs on her genitals.

Further evaluation is needed for culture and sensitivity testing for the causative agent and for commencing drug therapy for R.S. She must be referred to a gynecologist. Treatment of gonorrhea is pretty easy. However since some strains are resistant to certain antibiotics therefore it is best to prescribe two antibiotics to R.S., one as a shot and another in the form of a pill. The two most common antibiotics that can be used for treating gonorrhea in R.S. is ceftriaxone (as a shot), and azithromycin (orally) (Cole et al., 2020). R.S. must be given sex education intervention therapy. She should be referred for counseling to social worker who is certified. She will educate R.S. on sexual behaviors and alternative approaches that she must utilize while engaging in sexual activities to lower her chances of acquiring an ST (Hilliard, Senior & Hospice, 2019)Focused SOAP Note Template Of Gonorrhea Diagnosis.

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A comprehensive assessment of R.S.’s condition was conducted which diagnosed her with gonorrhea, an STD. The preceptor’s treatment of gonorrhea for R.S. is relevant and according to the treatment guidelines recommended by the Centers for Disease Control and Prevention. This case gave a thorough understanding of the bacterial infection. However, an evaluation of at least one of R.S’s partners would have given more profound data for presenting her case in a better manner. Gonorrhea can be prevented by using condom while having sexual intercourse, limiting the number of sexual partners, and considering regular gonorrhea screening. Since R.S. was in the age group of 20- 24 years she as therefore at an increased risk of acquiring this STI. The rate of gonorrhea is also 30 times more among African Americans than in whites, or Latinos which put R.S. at an increased risk (Coudray et al., 2021) Focused SOAP Note Template Of Gonorrhea Diagnosis