Case Study 1
Charlene Baja is a 22-year-old G0 P0 L0 presents to the clinic today for burning and discharge for 1 week. She states her boyfriend recently found out he was positive for chlamydia. She denies any other partners besides him. â€¯Her medical history isâ€¯remarkable for anxiety and depression. â€¯Her surgical historyâ€¯is unremarkable. Her social history includes socialâ€¯alcohol, but she denies tobacco and any recreational drugs.â€¯ She has no known drug allergies and takes a multivitamin and Srintec daily for oral contraception. Her health historyâ€¯reveals that her mother is alive with breast cancer in remission and hypothyroidism. Her paternal grandfather is alive with prostate cancer. Her sister has type 1 diabetes as well. Her father has HTN, diabetes type 2, and hyperlipidemia. â€¯Charlene has one brother with no medical history.
Â· Height 5â€™ 5â€_x009d_â€¯Weightâ€¯148â€¯(BMI 24.6),â€¯BP 132/68 Pâ€¯62
Â· HEENT:â€¯ WNL
Â· Neck: lymph nodes grossly normal
Â· Lungs/CV: Chest is clear to auscultation bilaterally, normal respiration, rhythm, and depth upon exam
Â· Breast: normal breast exam
Â· Abd: WNL
Â· VVBSU: WNL
Â· Cervix: firm, smooth, yellow watery discharge in large amount present
Â· Uterus: RV, mobile,â€¯non-tender
Â· Adnexa: WNL
OCUSED SOAP NOTE with your differential diagnosis. Include the additional questions you would ask the patient. Be sure to include an explanation of the tests you might recommend, ruling out any other issues or concerns and include your rationale. Be specific and provide examples. Use your Learning Resources and/or evidence from the literature to support your explanations.