SOAP Note: Chlamydia Essay Assignment Paper
SOAP Note: Chlamydia Essay Assignment Paper
SOAP Note: Chlamydia Essay Paper
Patient Initials: J. T
Sex: Female
Age: 15-years old
Subjective
Presenting Complaint: Swelling inside the vagina and itching around the genitals.
HPI: A 15-year-oldfemale visits the clinic complaining of lumps inside her vagina and itching around her genitals. Additionally, the client complains of abnormal and strong-smelling vaginal discharge. She also urinates frequently and experienced a burning sensation when passing urine.
Medications: She had not taken any medication.
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ROS:
General: Discomfort while sitting down due to pain in the tummy. She denies fatigue, fever, and chills.
HEENT: Denies blurry vision. SOAP Note: Chlamydia Essay Paper
GIT: Denies vomiting or constipation.
Urinary: Admits frequent urination, pain while passing urine, and abnormal and strong-smelling vaginal discharge.
Genital: Denies blood in the stool
Objective
General Exam: Well-groomed and presentable.
Skin: Smooth and glowing skin.
Lungs: No cough
Peripheral vascular: Normal heartbeat.
Genital: Abnormal, yellowish, and smelly vaginal discharge. No traces of blood in the urine.
Assessment
Diagnosis: The client is primarily diagnosed with chlamydia. This condition is characterized by abnormal, yellowish, orsmelling vaginal discharge. This symptom was presented by the client. Additionally, this condition is characterized by swelling inside the vagina. Lump inside the vagina and itchiness around the genitals were the chief complaints that were presented by the client. More so, the client complained of frequent urination and a burning sensation while urinating. These symptoms characterize chlamydia in a female. SOAP Note: Chlamydia Essay Paper
Plan
Medication: Doxycycline 100 mg was administered orally twice daily for 7 days. According to Peyriere et al. (2018), this medication is safe and effective in treating chlamydia among teenagers.
Patient education: The patient was advised to ensure that all her sexual partners in the past two months were treated. The treatment is compulsory even if one does not have any symptoms of the disease.
Follow-up care: Theclient was to return to the clinic in case of reoccurrence of the presented symptoms.
References
Peyriere, H., Makinson, A., Marchandin, H., & Reynes, J. (2018). Doxycycline in the management of sexually transmitted infections. Journal of Antimicrobial Chemotherapy, 73(3), 553-563.
Subjective
Presenting Complaint: Swallowing a dime.
HPI: A 2 -year-old male is accompanied by his mother to the clinic after swallowing a dime. The child was touching his chest while crying indicating that he was experiencing some pain in the chest. Additionally, he had difficulty breathing. He was also scratching his throat indicating that something might have stuck in the throat.
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