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Be concise, thorough and use headings for your SOAP note. When answering the que
Be concise, thorough and use headings for your SOAP note. When answering the questions at the end of the scenario, please number them as they are in the scenario.
Case Study 1
Scenario 1
Charlene Baja is a 22-year-old G0 P0 L0 presents to the clinic today for burning and discharge for 1 week. She states her boyfriend recently found out he was positive for chlamydia. She denies any other partners besides him. Her medical history is remarkable for anxiety and depression. Her surgical history is unremarkable. Her social history includes social alcohol, but she denies tobacco and any recreational drugs. She has no known drug allergies and takes a multivitamin and Srintec daily for oral contraception. Her health history reveals that her mother is alive with breast cancer in remission and hypothyroidism. Her paternal grandfather is alive with prostate cancer. Her sister has type 1 diabetes as well. Her father has HTN, diabetes type 2, and hyperlipidemia. Charlene has one brother with no medical history.
Height 5’ 5” Weight 148 (BMI 24.6), BP 132/68 P 62
HEENT: WNL
Neck: lymph nodes grossly normal
Lungs/CV: Chest is clear to auscultation bilaterally, normal respiration, rhythm, and depth upon exam
Breast: normal breast exam
Abd: WNL
VVBSU: WNL
Cervix: firm, smooth, yellow watery discharge in large amount present
Uterus: RV, mobile, non-tender
Adnexa: WNL
QUESTION:
What other information do you need?
MORE QUESTIONS:
Has she used or tried any treatments so far?
When did she find out about her partner’s positive chlamydia status?
When was her last gyn exam and what were the results of the tests?
Has she had any STD testing in the past?
Is she concerned with any other STDs?
What are your next steps/considerations?
What education should you provide?
What treatments are appropriate for Elaine?
Please post your FOCUSED SOAP NOTE with your differential diagnosis. Include the additional questions (additional questions ONLY related to the HPI/CC) you would ask the patient. Be sure to include an explanation of the tests you might recommend, ruling out any other issues or concerns, and include your rationale. Be specific and provide examples. Use your Learning Resources and/or evidence from the literature to support your explanations. Your differential diagnosis, additional questions, additional diagnostic tests, and rationales are what this assignment and grading are focused on. Your critical thinking for this assignment
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