Assessment And Diagnostic For Sexually Transmitted Infections Discussion

Assessment And Diagnostic For Sexually Transmitted Infections Discussion

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The 24-year-old female patient S.L.’s case raises concerns about possible sexually transmitted infections (STIs) and gives a thorough overview of her health. I support the healthcare provider’s comprehensive assessment and diagnostic strategy, which takes into account the patient’s symptoms, risk factors, and the positive findings of numerous tests. A comprehensive understanding of the patient’s health is facilitated by the documentation, which succinctly summarizes the patient’s medical history, social and drug use, and reproductive history (Workowski et al., 2021)Assessment And Diagnostic For Sexually Transmitted Infections Discussion. The patient’s symptoms and diagnostic findings are consistent with the primary and differential diagnoses. Based on the positive results of the physical examination and diagnostic tests, I agree that gonorrhoea, chlamydia, trichomonas, and cervicitis are possible causes of her symptoms. The regimen, which calls for the use of Doxycycline, Ceftriaxone, and Ibuprofen, seems reasonable and complies with current medical standards for the treatment of such infections.


I appreciate that the management plan includes patient education, stressing the value of HPV vaccination, safe sexual behavior, and contraceptive use. These suggestions can improve the patient’s general health and are in line with preventive healthcare practices (Workowski et al., 2021). In addition, the inclusion of particular questions about sexual behaviors and risk factors in the follow-up plan shows a proactive approach to addressing potential health risks and guaranteeing comprehensive care. In conclusion, the medical professional has carried out a thorough evaluation, made pertinent diagnoses, and created a thorough treatment and education plan for S.L. A patient-centered approach is evident in the SOAP note, which takes into account the patient’s overall health and lifestyle in addition to their current symptoms. To manage STIs and promote long-term health and well-being, a holistic approach is essential (Fasciana et al., 2022)Assessment And Diagnostic For Sexually Transmitted Infections Discussion.


Workowski, K. A., Bachmann, L. H., Chan, P. A., Johnston, C. M., Muzny, C. A., Park, I., Reno, H., Zenilman, J. M., & Bolan, G. A. (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports, 70(4), 1–187.

Fasciana, T., Capra, G., Lipari, D., Firenze, A., & Giammanco, A. (2022). Sexually Transmitted Diseases: Diagnosis and Control. International journal of environmental research and public health, 19(9), 5293.

Respond to your colleagues’ post and explain how you might think differently about the types of diagnostic tests you would recommend and explain your reasoning. Use your Learning Resources and/or evidence from the literature to support your position. NEED 2 Scholarly references APA Format. DO NOT NEED COVER PAGE

 Case Study 2: STI Investigation

Episodic/Focused SOAP Note Template

Patient Information:

Initials: S.L Age: 24 Sex: Female. Race: Caucasian.


CC (chief complaint): “I’m here for regular gyn care.”

HPI: The patient is S.L a 24 y/o Caucasian female who presents in the office for regular gyn care. She also complaints of fever for a day or two and a sore throat for the past 3 weeks. She has been bleeding after sex for the past 6 weeks. She admits having unprotected sex with different male partner for the past 12 months. The patient reports trying Tylenol which helped relieve her fever. No other complaints reported

Current Medications:

  • She tried Tylenol for fever.
  • Midol takes occasionally for her cramps

Allergies: None

PMHx: She has negative history of chronic conditions. Her immunizations are up to date. However, she denies receiving HPV vaccine

Soc & Substance Hx: The patient is currently single though she has multiple partners. She lives in Oklahoma where she was born and grew. She is currently living in her on apartment. She works as an administrative assistant in insurance company in the town. She reports that she really love her job. She has since age of 14. She been an active smoker for the past 10 years. She has been smoking a half pack per day. She also drinks 6-8 drinks of hard liquor daily and EtOH only during weekends. She smokes weed daily. The patient is physically active. She jogs 3-4 times a week. Her health promotion activities include ocassional use of sunscreens and use of seatbelts when in the car. Assessment And Diagnostic For Sexually Transmitted Infections Discussion

Fam Hx: Non-contributory

Surgical Hx: No medical surgical history

Mental Hx: No history of mental health issues. Denies anxiety, depression, self-harm, suicidal ideas or delusions.

Violence Hx: Denies concerns of bullying, insults, screaming or sexual abuse from her partners.

Reproductive Hx: The patient reports an onset of menses at the age of 13. They are regular, occurs every 28-32 days. Her periods lasts 4-6 days with some cramps. She takes Midol for the cramps which is an over the counter medication. Her periods are moderate bleeding, she uses 3 tampons daily. Denies current or any pregnancy desire. Pt. reports that she is sexually active. She relates having multiple partners male and females for the past 12 months. She uses condoms but sometimes she doesn’t use them occasionally especially due to heavy alcoholic drinking. Denies receiving HPV vaccine. She has no history of STIs. However, she rarely goes for STI testing. Assessment And Diagnostic For Sexually Transmitted Infections Discussion


GENERAL: Positive for fever for one or two days, relieved by Tylenol. Denies headaches, appetite or any weight change.

HEENT: Positive of sore throat. No headaches, blurry vision, hearing problems, runny nose, sinus pressure or mouth sores.

CARDIOVASCULAR: No palpitations, edema, cold or blue skin

RESPIRATORY: No breathing problems, wheezing, sputum or cough reported


NEUROLOGICAL: No headaches, dizziness, syncope or lightheadedness

MUSCULOSKELETAL: No pelvic pain reported

HEMATOLOGIC: Reports abnormal bleeding after sex. No history or problems with anemia.

LYMPHATICS: No swollen lymph nodes.

PSYCHIATRIC: No history of depression or anxiety.

GENITOURINARY/REPRODUCTIVE: Reports bleeding after intercourse for the past 6 months. Denies breast problems, nipple discharge or lumps. No urinary urgency, painful urination or incontinence


ALLERGIES: No known drug allergies


Physical exam:

Vital signs:

  • 112/64, Pulse 68 bpm, Temperature 97.8.
  • Height 5’6”, weight 118 lbs. BMI 19.04.

HEENT: Head: normocephalic and atraumatic, symmetric facial features. Eyes: Anicteric sclera, pink conjunctiva. PERRL. ENT: No nasal discharge. Erythema noted on inspection of throat. Anterior cervical adenopathy.

Cardiovascular: Regular sinus rhythms, S1 and S2 sounds audible, no murmurs or gallop.

Respiratory: Lungs clear to auscultation.

Abdomen: the abdomen is soft. The liver is normal and non-tender.

Breasts: there are no masses, dimpling, or discharge on the breasts. There are no adenopathy and bilateral nipple piercings. Their fibrocystic changes bilaterally. Assessment And Diagnostic For Sexually Transmitted Infections Discussion

Diagnostic results:

Pelvic Exam:

  • VVBSU:Clitoral piercing noted. Slight frothy yellow discharge by cervix
  • Cervix:Friable cervix and petechia noted. No motion tenderness noted.
  • Uterus:Mid mobile and non-tender.

Throat Culture: Positive for GC infection.

Wet Mount: to observe any motile organisms. Positive for trichomonas.

Pap test: Positive for Positive for elevated white blood cells.

NAAT: to test for gonorrhea and chlamydia trachomatis infection. Positive for GC/CT.

Whiff test: Positive

HIV test: Negative

Urine pregnancy test: Negative


Primary and Differential Diagnoses

Gonorrhea (A54.9): It is one of the main sexually transmitted infection in reproductive women. It mainly affects genitourinary tract with its manifestation ranging from asymptomatic to complicate types. According to Qian-Qiu, et al, (2020), the primary site of infection includes pharynx, rectum and conjunctiva. When infected in the pharynx, the patient may experience burning, discomfort or pain in the pharynx. The physical exam may display pharyngeal mucosa with purulent discharge and erythema. The risk factors associated with this infection include unsafe sex, multiple partners, previous diagnosis of STDs and others. It can be tested using Nucleic Acid Amplification Tests, gram stain, and culture. This diagnosis was confirmed by Susan’s test results of throat culture and NAAT.

Chlamydia (A74.9): Chlamydia trachomatis is often a co-infection with GC. This infection is often associated with mucopurulent cervicitis and endometritis in women. It can lead to complications such as pelvic inflammatory disease, premature rupture of the membrane or conjunctivitis of the fetus due to ascension of the infection (Sood, et al, 2018). The clinical manifestation of CT closely resembles Neisseria gonorrhea infection.

Cervicitis: (A 54.03): it is one of the complications that results from N gonorrhea. Patients with cervicitis experience symptoms of increased and purulent vaginal discharge, red and swollen cervix, dyspareunia and itching. The physical exam of Susan reveals friable, yellow purulent discharge by cervix.

Trichomonas vaginalis (A 59.9): T vaginalis is considered more common as compared to C trachomatis and N gonorrhea. It is a non-viral STI. This parasite primarily infects the squamous epithelium of genital tract especially the vagina, urethra and endocervix. The clinical manifestation of this infection is mostly asymptomatic but may become symptomatic within 6 months (Kissinger, et al, 2022). The symptoms include yellow-green color vaginal discharge, erythema vaginal, pruritus in the genital region. Assessment And Diagnostic For Sexually Transmitted Infections Discussion



  • Doxycycline 100 mg BID.
  • 125 mg of Ceftriaxone IM single dose.
  • Ibuprofen 200 mg, two tabs, BID.


Patient Education:

  • Educate the patient on the importance of receiving HPV vaccine. It protects against genital warts, cervical cancer and other complications caused by HPV.
  • Educate the patient on safe sex, the use of condoms and other STI prevention strategies.
  • Use contraceptives such as DMPA injections, oral pills, Nexplanon implant to prevent pregnancy.
  • Refer your partner to the clinic for diagnosis and treatment
  • Reduce alcohol intake
  • Avoid tobacco and marijuana smoking since it increases risks for gynecological complications and other cancers.
  • Abstain from sex or use barrier contraceptives after initiation of treatment to prevent re-infection.

Follow-up: After completion of antibiotics for follow up tests.

Additional Questions:

1) How many partners have you had sex with in the past 12 months? This question would help identify the risks of getting STIs,

2) Have you noted abnormal vaginal discharge? If so how would you describe the discharge? Describing vaginal discharge would help identify the possible infections and also the appropriate interventions for this patient.

3) When was the last time you had HPV vaccine?

4) Do you feel any pelvic pain associated with your symptoms? This would help to identify any possibilities of pelvic inflammatory disease.

5) Do you engage in risky sexual behaviors after drinking alcohol? It would help to explore the key risk factors and how alcohol drinking is associated with her infections.


Kissinger, P. J., Gaydos, C. A., Seña, A. C., Scott McClelland, R., Soper, D., Secor, W. E., Legendre, D., Workowski, K. A., & Muzny, C. A. (2022). Diagnosis and management of Trichomonas vaginalis: Summary of evidence reviewed for the 2021 Centers for Disease Control and Prevention sexually transmitted infections treatment guidelines. Clinical Infectious Diseases, 74(Supplement_2), S152-S161. to an external site.

Sood, S., Bala, M., Mahajan, N., Kapil, A., Pandey, R., Mukherjee, A., Satpathy, G., Sharma, A., Sharma, V., & Samantaray, J. (2018). A pilot study for diagnosis of genital chlamydia trachomatis infections by polymerase chain reaction among symptomatic Indian women. Indian Journal of Dermatology, Venereology, and Leprology, 78(4), 443. Links to an external site.

Wang, Q., Zhang, R., Liu, Q., Xu, J., Su, X., Yin, Y., Qi, S., Xu, D., Zhou, P., Li, Y., Li, X., Wu, M., Zou, X., Yang, L., Chen, X., Gong, X., Liang, G., Jiang, J., Cheng, H., … Ge, F. (2020). National guidelines on diagnosis and treatment of gonorrhea in China (2020)#. International Journal of Dermatology and Venereology, 3(3), 129-134. to an external site.


Class Resources:

  • Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care (4th ed.). Jones and Bartlett Learning.
    • Chapter 17, “Breast Conditions” (pp. 337-349)
    • Chapter 18, “Alterations in Sexual Function” (pp. 353-364)
    • Chapter 20, “Infertility” (pp. 383-398)
    • Chapter 21, “Gynecologic Infections” (pp. 401-432)
    • Chapter 22, “Sexually Transmitted Infections” (pp. 437-466)
  • Reproductive Health Access Project (2020). Your birth control choicesLinks to an external site..
  • Office of Women’s Health: (2017). Birth control methodsLinks to an external site.. Assessment And Diagnostic For Sexually Transmitted Infections Discussion

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