Annie Wagner SOAP notes
Assessment
Cervicitis
This refers to the inflammation of the ectocervix and can be caused by non-infectious or infectious agents like Neisseria gonorrhea, trichomonas vaginalis or chlamydia trachomatis. Patient can be symptomatic or asymptomatic. Signs and symptoms includes; mucoid/yellowish discharge, urinary symptoms like dysuria, increased frequency, dyspareunia or abdominal pain, they have history of multiple partners, previous history of STIs, they do not use protection from STIs. Vaginal exam shows purulent mucoid and a friable cervix (Iqbal et al.,2023). Annie presents with dysuria, mucoid vaginal discharge, she has multiple sexual partners, she had recurrent bladder infection and does not use condom. Examination shows mucopurulent vaginal discharge and a friable cervix. Lab test shows Neisseria and this qualifies it to be the most probable diagnosis.
Urinary tract infection (UTI)
UTI is an infection involving urinary tract; ureters, bladder, urethra and kidneys. It is mainly caused by E.coli bacteria and patients mainly presents with dysuria, frequency, urgency, back or flank pain, pelvic pain, nausea, vomiting, high fever or chills (Tan et al.,2016). In our case, patient only present with burning when urinating, urgency and increased frequency. She does not present with flank/back pain, nausea, vomiting or high fever and hence not the most probable diagnosis.
Candida vaginitis.
This is a vaginal fungal infection caused by candida albican. It is also known as vaginal yeast infection or vulvovaginal candidiasis. Signs and symptoms include; abnormal vaginal discharge which is whitish, thick and cheese like and odorless, dyspareunia, vaginal itchiness and dysuria (Centers for Disease Control and Prevention, 2022). Annie in this case does not vaginal itchiness, has cheese like discharge, the discharge is yellowish and smelly and this rule out Candida vaginitis as the most probable diagnosis.
Bacterial Vaginosis
This is a bacterial disease, patients present with fishy-smelling vaginal discharge which recurs around the time of menstruation, dysuria, vaginal itchiness (Hay et al., 2017). Annie does not have a fishy-smelling vaginal discharge and denies vaginal itchiness.
Final Diagnosis:
Cervicitis
Plan
Pharmacology
Ceftriaxone intramuscular 250mg once
Azithromycin PO 1g single dose
Ibuprofen PO 400mg tid when needed.
Non-Pharmacology
Treatment of sexual partners is recommended.
Abstain from sexual intercourse until the completion of medication to prevent reinfection.
Diagnostics
Chlamydia trachomatis culture.
Potassium hydroxide (KOH) preparation test.
Urinalysis
Urine culture
HIV 1 and 2 antibody blood.
Neisseria gonorrhea culture
Saline wet mount.
Consults/Referrals
Consult a gynecologist and an infectious disease specialist.
No referral needed at the moment.
Patient Education
Patient is educated on her diagnosis and treatment given.
She is advised to use condom when having sexual intercourse.
She should be going for regular STIs screening.
Avoid having multiple partners.
She should avoid alcohol.
She is advised to eat well balanced meals and drink plenty water.
Follow Up
Patient should come after one week if no improvement.
To come after 3 months after treatment for gonorrhea retest.
References
Centers for Disease Control and Prevention, N. C. (2022). Vaginal Candidiasis. Fungal Diseases
Hay, P. (2017). Bacterial vaginosis. F1000Research, 6. doi: 10.12688/f1000research.11417.1
Iqbal U, Wills C. Cervicitis. [Updated 2023 Mar 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562193/
Tan, C. W., & Chlebicki, M. P. (2016). Urinary tract infections in adults. Singapore medical journal, 57(9), 485.
Value: 100 points
Due: 7
Gradebook Category: Assignments—iHuman Assignments
Introduction
The iHuman platform is an opportunity for you to interact with a simulated patient and gather data. When working in iHuman, practice as if this were a real patient. For example, the platform allows you to ask several questions when taking a patient history. In real life, you likely will be limited in time. Practice setting yourself a patient history time limit and work on being efficient in your clinical interview.
If you require technical support with the iHuman platform, use the iHuman Help Center to contact iHuman Technical Support directly. Technical support only includes a malfunction of the platform; they cannot help with issues involving content!
Instructions
In this assignment, you will review a patient scenario in iHuman. Please see the course announcement for the case assigned this week. Your deliverable for this assignment is a paper based on the iHuman Soap Note Template (Word).
Follow the requirements listed in the iHuman Soap Note Template.
When your iHuman Soap Note Template is complete, upload it to this assignment.
All papers must conform to the most recent APA standards.
Please refer to the Grading Rubric for details on how this assessment and plan is graded.
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Select the Add Submissions button.
Drag or upload your files to the File Picker.
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Submission status
iHuman Moodle Rubric
CriteriaExceeds ExpectationsMeets ExpectationsNeeds ImprovementInadequateTotal PointsSubjective – 40%Determined by iHuman 40 pointsDetermined by iHuman 36 pointsDetermined by iHuman 32 pointsDetermined by iHuman 0 points40Objective – 25%Determined by iHuman 25 pointsDetermined by iHuman 22 pointsDetermined by iHuman 20 pointsDetermined by iHuman 0 points25Objective – 5% (Testing)Determined by iHuman 5 pointsDetermined by iHuman 4 pointsDetermined by iHuman 3 pointsDetermined by iHuman 0 points5Assessment—5%Three differential diagnoses are supported by findings and include worst-case scenario.
Rationale for differential diagnoses provided by scholarly resources.
5 pointsThree differential diagnoses include worst-case scenario, but one diagnosis might not be fully supported by findings.
Rationale for differential diagnoses provided by scholarly resources.
3 pointsDifferential diagnoses may or may not include worst-case scenario, and two differential diagnoses are not supported by findings.
Rationale for all differential diagnoses not provided by scholarly resources.
1 pointsFewer than three differential diagnoses identified, or differential diagnoses not supported by findings and do not include worst-case scenario.
Scholarly resources not provided or do not support differential diagnoses.
0 points5Plan—25%Comprehensive plan includes all components: Diagnostic testing Pharmacologic intervention Non-pharmacologic intervention Referrals Patient education Follow-up Appropriate and current guidelines cited.
25 pointsPlan missing one of the identified components: Diagnostic testing Pharmacologic intervention Non-pharmacologic intervention Referrals Patient education Follow-up Appropriate and current guidelines cited.
17 pointsPlan missing two of the identified components: Diagnostic testing Pharmacologic intervention Non-pharmacologic intervention Referrals Patient education Follow-up Guidelines are not current or appropriate for identified problem.
9 pointsPlan missing more than three of the identified components: Diagnostic testing Pharmacologic intervention Non-pharmacologic intervention Referrals Patient education Follow-up Guidelines for plan not cited.
0 points25Total
