A) Please fallow instruction. I need you to make up a soap note for a female patient with diagnoses of Chlamydia. Please fill out the template. I include the soap note template you must plug the information, the rubric to follow in separate attachments. I need you to provide the following: APA format with references at least no older than 5 years.
- 1)The Diagnosis ICD 10 code
- 2) 3 differential diagnoses with ICD 10 code.
- 3)Vital sign, BMI
- 4)Complete Chief patient compliant
- 5)Subjective Information
- 6)PMH, PSH, FH, ROS completed. Provide complete and concise summary of pertinent information.
- 7)Complete Objective Information
- 8)Lab Tests
- 9)Allergies
- 10)Complete physical exam with critical elements related to subjective data.
- 11)Perform Assessment
- 12)Minimum of 3 differentials supported by S + O data. Final diagnosis noted and optimal and thorough subjective and objective assessment is presented for final diagnosis.
- 13)Create a Plan
- 14)Plan includes pharmacologic and nonpharmacologic treatments as well as education provided. The plan is supported by evidence/guidelines, and the follow-up plans are noted.
- 15)Self-Assessment & Clinical Guidelines
- 16)Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence based reasoning and literature in designing plan of care, compare to plan of care.
B) Discuss of Chlamydia
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Introduction: This assignment requires the creation of a SOAP note for a female patient with a diagnosis of Chlamydia. The SOAP note must meet specific requirements, including diagnosis and differential diagnoses with ICD 10 codes, vital signs, subjective and objective information, lab tests, complete physical exam, assessment, plan, and self-assessment. Additionally, this answer will provide a discussion of Chlamydia.
A) SOAP Note for Female Patient with Chlamydia Diagnosis
Diagnosis ICD 10 Code: A56.01
Differential Diagnoses:
1. Gonococcal infection – A54.00
2. Trichomoniasis – A59.00
3. Herpes genitalis – A60.00
Vital Signs:
– Blood pressure: 120/80 mmHg
– Heart rate: 85 bpm
– Respiratory rate: 16 breaths/min
– Temperature: 98.5°F
– BMI: 24 kg/m²
Chief Patient Complaint:
“Having vaginal discharge, pain during urination, and pain during sex for the last four days.”
Subjective Information:
The patient reports that she has been sexually active with multiple partners for the last few months. She has not used any protection during sex. She reports that she has had a recent change in her vaginal discharge, which has become more frequent, yellowish, and foul-smelling. She also reports pain during urination and sexual intercourse.
PMH, PSH, FH, ROS:
The patient has no significant past medical history, no previous surgeries, and no significant family history. The review of systems (ROS) is positive for dysuria, pelvic pain, and vaginal discharge.
Objective Information:
On examination, the patient appears in mild distress. She has no visible signs of discomfort. Abdominal examination reveals no palpable masses, hepatosplenomegaly, or organomegaly. Pelvic examination reveals yellowish-greenish discharge from the cervix, cervix is erythematous, bimanual examination is tender.
Lab Tests:
– Chlamydia/Gonorrhea Testing – +ve for chlamydia
Allergies:
The patient has no known allergies.
Complete Physical Exam with Critical Elements Related to Subjective Data:
– Abdominal examination
– Pelvic examination with bimanual examination
Assessment:
The patient is diagnosed with Chlamydia (A56.01). The following three differential diagnoses were also considered: Gonococcal infection (A54.00), Trichomoniasis (A59.00), and Herpes genitalis (A60.00). However, given the negative test results, these differential diagnoses have been ruled out.
Plan:
The patient will be started on Azithromycin (1 g orally) and consult with her sexual partner(s) for testing and treatment. She will receive counseling on safe sex practices and preventing the spread of the infection. A follow-up appointment in two weeks to ensure resolution of the infection.
Self-Assessment and Clinical Guidelines:
The quality and relevance of S + O data support the diagnosis of Chlamydia. Clinical evidence-based reasoning and literature on Chlamydia indicate that Azithromycin has excellent outcomes in treating chlamydia. The decision to prescribe Azithromycin is consistent with the current CDC guidelines for the treatment of Chlamydia infections.
B) Discussion of Chlamydia
Chlamydia is a bacterial sexually transmitted infection (STI) caused by the bacteria Chlamydia trachomatis. It is a common STI with approximately 1.7 million cases reported in the United States each year. Chlamydia can be easily transmitted through sexual contact, including vaginal, anal, and oral sex. Most people with Chlamydia have no symptoms, which can lead to the spread of the infection to sexual partners unknowingly.
Chlamydia can lead to serious health problems if left untreated, including pelvic inflammatory disease (PID) in women, which can result in infertility or ectopic pregnancy. Men can develop epididymitis, which can cause sterility. Pregnant women with Chlamydia may pass the infection to their baby during childbirth, leading to eye infections or pneumonia in newborns.
Testing and treatment for Chlamydia are essential to prevent further spread and complications. Testing includes urine analysis, vaginal swab, or cervical swab. Treatment options include antibiotics such as Azithromycin or Doxycycline. Follow-up testing is recommended to ensure the infection has been completely resolved. Counseling on practicing safe sex is also important to prevent the spread of Chlamydia and other STIs.
