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.

Case Scenario 1

 Table 1

Infection	Description	Presentation	Causes/ Risk Factors		Treatment per CDC	Addtl info
Candida
BV
Chlamydia
Gonorrhea
Trichomonas
Cervicitis
PID
HIV
Syphilis
Hep B
Hep C
HSV

 

Table 2

Question	Answer
Name 10 Risk Factors for contracting STI’s 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 (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.  Lisa’s 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:
2. What other relevant questions should you ask regarding the HPI?
3. What other medical history questions should you ask?
4. What other social history questions should you ask?
5. Objective:
6. Explain what POCT will you order and perform, and discuss your rationale for ordering and performing each test.
7. Assessment/ Diagnosis:
8. What would be an appropriate diagnosis for her? Why?
9. Any other diagnosis or differential diagnosis you would like to add?
10. Plan:
11. 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
12. 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.
13. What patient education is important to include for this patient? (Consider when can the patient resume sexual activity)
14. Explain complications that can occur if patient does not comply with treatment regimen.