To prepare:
By Day 1 of this week, you will be assigned to a specific case study scenario for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
Review the Learning Resources for this week and specifically review the clinical guideline resources specific to your assigned case study.
Use the Focused SOAP Note Template found in the Learning Resources to support your Discussion. Complete a FOCUSED SOAP note and critically analyze this and focus your attention on the diagnostic tests. Please post your FOCUSED SOAP note. This information will help you develop your differential diagnosis and additional questions
By Day 3
Please POST your FOCUSED SOAP NOTE and post your primary diagnosis. Include the additional questions you would ask the patient and explain your reasons for asking the additional questions. Then, explain the types of symptoms you would ask. Be specific and provide examples. (Note: When asking questions, consider sociocultural factors that might influence your question decisions.)

Based on the preemptive diagnosis, explain which treatment options and diagnostic tests you might recommend. Use your Learning Resources and/or evidence from the literature to support your recommendations.   Case Study on STI Investigation Focused SOAP Note of 24 Year-Old Caucasian Female Susan Lang Essay

Susan Lang is a 24-year-old Caucasian female presenting to the clinic for regular care. She works full-time as an administrative assistant, and relates she loves her job. She has no medical or surgical history, takes no medication, and has no allergies. Family history is non-contributary. Social history is remarkable for cigarette smoking at a rate of ½ packs per day (PPD) since age 14, / ETOH only on weekends, 6-8 hard liquor/ daily, and marijuana smoking. Gyn history is onset of menses age 13, menses every 28-32 days, lasting 4-6 day and using 3 tampons daily. She has some cramping during her menses for which she takes otc Pamprin. She jogs 3-4 times a week, wears seatbelts when in the car, and “occasionally” uses sunscreen. Susan relates she has been having some postcoital bleeding for the past 6 weeks and has had a sore throat for past 3 weeks. She did have a fever for a day or two, but Tylenol took care of it and she thought it was allergies.

Susan’s vital signs are taken and were temperature 97.8, pulse 68, BP 112/64, height 5’6” and weight 118 lbs. (which was the same as last year). BMI 19.04

• HEENT: WNL except some anterior cervical adenopathy bilaterally, and throat appears reddened.
• Lung: clear to auscultation
• CV: regular sinus rhythms without murmur or gallop
• Abd: soft, non-tender, liver normal,
• Breasts: fibrocystic changes bilaterally, no masses, dimpling, redness or discharge, no adenopathy, and bilateral nipple piercings.
• VVBSU: wnl, slight frothy yellow discharge by cervix, clitoral piercing noted
• Cervix: friable, some petechia no cervical motion tenderness.
• Uterus: mid mobile, non-tender
• Adnexa: without masses or tenderness
• Perineum: wnl
• Rectum: wnl
• Extremities: full rom, skin clear, no edema, reflexes 1+.
• Neurological: CN II-12 grossly intact.

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Main Posting:

Response to the case study discussion questions includes appropriate diagnoses with explanations of appropriate diagnostic tests and treatment options as directed, is based on evidence-based research where appropriate, and is incorporates syntheses representative of knowledge gained from the course readings for the module and current credible sources.–

Excellent
Point range: 90–100 40 (40%) – 44 (44%)
Good
Point range: 80–89 35 (35%) – 39 (39%)
Fair
Point range: 70–79 31 (31%) – 34 (34%)
Poor
Point range: 0–69 0 (0%) – 30 (30%)
Main Posting:

Writing–

Excellent
Point range: 90–100 6 (6%) – 6 (6%)
Good
Point range: 80–89 5 (5%) – 5 (5%)
Fair
Point range: 70–79 4 (4%) – 4 (4%)
Poor
Point range: 0–69 0 (0%) – 3 (3%)
Main Posting:

Timely and full participation–

Excellent
Point range: 90–100 9 (9%) – 10 (10%)
Good
Point range: 80–89 8 (8%) – 8 (8%)
Fair
Point range: 70–79 7 (7%) – 7 (7%)
Poor
Point range: 0–69 0 (0%) – 6 (6%)

Case Study on STI Investigation: Focused SOAP Note of 24 Year-Old Caucasian Female Susan Lang

Patient Information:

Initials:    S.L.             Age:    24 years           Gender:  F       Race:    Caucasian

Subjective:

CC (chief complaint): The patient comes with a complaint of post-coital bleeding for the last six weeks. She also says she “had a sore throat” for the past three weeks as well as fever that lasted for about two days and disappeared after using acetaminophen (Tylenol).

HPI: The patient is a 24 year-old Caucasian female who presents with the above complaints. She denies having a past history of the post-coital bleeding that has been there for about a month and a half. The onset of the current symptoms was six weeks ago. The location of the symptoms is the genitourinary system as she has p.v. bleeding after intercourse. The bleeding is intermittent in duration but consistent. The bleeding is characteristically painless but relentless. It s aggravated by intercourse and somewhat relieved by the application of a cold tampon. The timing of the bleeding is after sexual intercourse and it occurs day and night afterwards. On a scale of 1-10, the patient rates its severity at 7/10.

Current Medications: She is not on any medications currently.

Allergies: She does not have any known allergies (NKDA).

PMHx: There is no significant medical or surgical history on the part of patient S.L.

Sc Hx: The patient has been smoking half a pack of cigarettes per day since she was 14 years old. That is now a total of 5 pack years. She only takes alcohol over the weekends but during that time she takes she takes 6-8 hard liquor servings a day. She also admits to smoking cannabis regularly. She exercises three to four times a week through jogging and uses sunscreen from time to time. When driving she does not use the phone and wears a seatbelt always. The house she lives in has a smoke detector and the locality has all the necessary amenities like clean drinking water and a garbage collection service.

Family Hx: Her family history is non-contributory as it has no relationship to her current condition.

ROS:

• GENERAL: She is negative for fatigue, fever, weight loss, or chills.
• HEENT: She denies photophobia, tinnitus, otorrhea, and rhinorrhea. She however admits to sore throat and bilateral cervical lymphadenopathy.
• SKIN: Denies rashes, itching, or eczema.
• CARDIOVASCULAR: Denies chest pains or discomfort and edema.
• RESPIRATORY: Denies shortness of breath, coughing, or producing sputum.
• GASTROINTESTINAL: Denies a change in bowel habits, nausea, vomiting, or diarrhea.
• GENITOURINARY: POSITIVE for post-coital bleeding but negative for lesions.
• NEUROLOGICAL: Denies dizziness, syncope, paraesthesia, or paresis.
• MUSCULOSKELETAL: Denies muscle pain, joint pains, or back pain.
• HEMATOLOGIC: Denies a history of bleeding or clotting disorders.
• LYMPHATICS: POSITIVE for cervical lymphadenopathy but negative for splenectomy.
• ENDOCRINOLOGIC: Denies previous hormonal therapy, polydipsia, polyphagia, excessive sweatiness, cold intolerance, or heat intolerance.  Case Study on STI Investigation Focused SOAP Note of 24 Year-Old Caucasian Female Susan Lang Essay
  

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Objective:

Physical Examination

Vital signs: Temperature 97.8; Pulse 68; BP 112/64; Height 5’6” and weight 118 lbs (BMI 19.04 kg/m² = normal weight for height)

HEENT: There is bilateral cervical lymphadenopathy and the throat is erythematous.

Respiratory: Both lung fields are clear with no crepitations, rales, rhonchi, or crepitations.

Cardiovascular: S1 and S2 are audible with normal sinus rhythm and rate. There are no murmurs, gallops, or bruits.

Breasts: There are no masses felt but fibrocystic changes noted bilaterally. She has bilateral nipple piercings but no dimpling, no adenopathy, no discharge, and no redness.

Genitourinary: The clitoris is pierced and there is a frothy yellow discharge from the cervix. The cervix is friable but non-tender. The uterus is mobile but also non-tender. The adnexae show no tenderness or masses. The perineum and rectum have no notable lesions.

Diagnostic Results:

• WBC 6.3 x 10^-9 with no differential leucocytosis
• Hb 12.6 g/dL (mild anemia)
• Urinalysis is unremarkable

Assessment:

Differential Diagnoses

Cervicitis: This is the most likely primary diagnosis for patient S.L. Cervicitis that is acute is usually caused by infection of the cervix with organisms such as Chlamydia trachomatis, Neisseria gonorrhoeae, mycoplasma species, and Trichomonas vaginalis amongst other species (Godfrey et al., 2019; Hammer & McPhee, 2018; Huether & McCance, 2017).

Pelvic Inflammatory Disease (PID): This is an infection of the uterus, fallopian tubes, and/ or ovaries (upper reproductive tract organs). The cause is usually untreated sexually transmitted infections such as gonorrhea that ascends to the upper reproductive tract (Godfrey et al., 2019; Hammer & McPhee, 2018; Huether & McCance, 2017). Prompt treatment of STIs is what prevents PID.

Cervical cancer: Cervical cancer is the most common cause of post-coital bleeding. About 11% of women presenting with a complaint of post-coital bleeding have cervical cancer. During intercourse, the repeated friction on the cervix caused by the sexual act causes the bleeding from the diseased cervix (Godfrey et al., 2019; Hammer & McPhee, 2018; Huether & McCance, 2017). This is however not the primary diagnosis for this patient because of her age. She is still young and without a family history of cancer, it is unlikely that she would be having cervical cancer although it remains a possibility.

Plan:

1. Colposcopy to confirm the diagnosis and take swabs for culture
2. Antibiotics if culture reveals infection

• Removal of the clitoral piercing (that may also cause bleeding)

1. Vagina moisturizers if dryness is also suspected
2. Chemotherapy if it is confirmed by biopsy to be due to cancer.

Reflection

I performed the evaluation of this patient following the laid don protocols on physical examination and history taking (Bickley, 2017). Informed consent was obtained before doing the vaginal examination and taking samples. This respected autonomy as an ethical principle. The patient was given health education on the importance of safe sex and also screening for infections and cancer (HPV and Pap smear). I am to follow up the patient for the biopsy results to rule out cervical cancer and also to monitor the progress of treatment. 

References

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12^th ed. Wolters Kluwer.

Godfrey, M.A.L., Nikolopoulos, M., Povolotskaya, N., Chenoy, R., & Wuntakal, R. (2019). Post-coital bleeding: What is the incidence of significant gynaecological pathology in women referred for colposcopy? Sexual & Reproductive Healthcare, 22, 100462. https://doi.org/10.1016/j.srhc.2019.100462

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. McGraw-Hill Education.

Huether, S.E. & McCance, K.L. (2017). Understanding pathophysiology, 6^th ed. Elsevier, Inc.

Case Study on STI Investigation Focused SOAP Note of 24 Year-Old Caucasian Female Susan Lang Essay