Case Study: SOAP Note

Introduction

SOAP (Subjective, Objective, Assessment and Plan) enables organized and structured documentation by healthcare workers. SOAP note provides clinicians with a cognitive framework to facilitate their reasoning in the clinical setting (Ghassemzadeh & Lew, 2019). The organization of information by SOAP note makes the assessment, diagnosis, and treatment of patients by healthcare workers easy and orderly. Furthermore, SOAP the organization of information makes retrieval of documented information easy and it acts as a cognitive aid for healthcare personnel (Ghassemzadeh & Lew, 2019).

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Subjective

A 28-year-old female patient presents at the hospital with a two-day history of burning and pain on urination, pain in the lower abdomen, and a vaginal discharge that has been present for about a week. The chief complaint n presentation was a pain in the lower abdomen, pain n urination, and foul vaginal discharge. The patient explains that the symptoms are similar to that she experienced when she suffered when she had Urinary Tract Infection (UTI). She has had recurrent UTI in the past; three times in the given year. She has also suffered from gonorrhea twice and chlamydia once. The only surgical procedure that the patient has undergone was a tubal ligation done two years ago. Currently, the patient has three children and is single and lives with her current boyfriend. The patient also added that she has a history of multiple sexual partners. The patient also stated that she had unprotected sexual intercourse with her former boyfriend. The patient denied drinking alcohol, smoking, or using any other drug. The patient is allergic to sulfamethoxazole and trimethoprim. From the review of systems, the patient had a pap smear done six months ago, has no breast discharge, and has dark urine.

Objective

The significant vital signs the patient presented with include soft, tender, increased suprapubic tenderness, foul-smelling vaginal discharge, adnexal tenderness, and cervical motion tenderness. These symptoms are consistent with those of gonorrhea and chlamydia which are usually both characterized by pain in the lower abdomen and a foul discharge in females. The patient's blood pressure, heart rate, and temperature are normal.

From the laboratory and diagnostic tests carried out, the patient's urine was positive for gram-negative rods. Tests done on the cultured vaginal discharge revealed a positive result for, Neisseria gonorrhea, and positive monoclonal antibodies for chlamydia. The differential blood count done indicated normal ranges, with a slight elevation of neutrophils (although it still within the normal range).

Assessment

The appropriate diagnosis code for the given patient is ICD-10-CM code Z11.3 since her symptoms, and signs imply a sexual mode of transmission (STI Screening Under Medicare, 2015). Since she is a heterosexual female with a history of multiple sexual relations, the codes Z72.51 will also be used (STI Screening Under Medicare, 2015). Thereby, the ICD-10-CM coding is Z11.3, Z72.51. The procedure coding is 86631, 87850.

The patient's social history, specifically her sex life implies the presence of an STI. In addition to her presenting signs and symptoms, the appropriate tests to be done can be established. The results of the laboratory diagnosis thereby indicate that the patient has both gonorrhea and chlamydia.

Plan

From the assessment, it is clear that the patient has gonorrhea and chlamydia. Medical therapy is recommended for the patient. In the case of this patient, sulfamethoxazole and trimethoprim should not be included since the patient is allergic to the drugs. A susceptibility test to determine the presence of antimicrobial resistance is also vital for positive outcomes.

Currently, widespread resistance of several strains of Neisseria gonorrhea to antimicrobial therapy has been reported (CDC - Gonorrhea Treatment, 2019). It is recommended that patients diagnosed with the disease are put on dual antimicrobial therapy. An example of a combination is 250 milligrams of ceftriaxone and 1 gram of azithromycin per day (CDC - Gonorrhea Treatment, 2019). In the case of this particular patient, adherence to the therapy should be emphasized since she has a history of recurrent gonorrhea infection.

For chlamydia, the azithromycin administered will also be effective against the bacteria. Additionally, the wide spectrum of activity of the given antibiotics will also treat the recurrent UTI reported by the patient.

For the case of sexually transmitted infections, the effectiveness of therapy will also entail the involvement of relevant sexual partners (CDC - Gonorrhea Treatment, 2019). In the case of the given patient, it is recommended that her current spouse undergoes tests to establish if he is also infected. If infected, the appropriate steps should be taken to treat the diseases. The patient should also be advised to engage in sexual intercourse with protection, especially when there are multiple sexual partners.

In essence, the given patient should be placed on the appropriate pharmacotherapy and take the necessary measures to prevent recurrence. In the case of the particular patient, follow up should be done to assess the effectiveness of therapeutic interventions since she has had a history of recurrent infections.

References

CDC - Gonorrhea Treatment. (2019, January 11). Retrieved February 12, 2019, from https://www.cdc.gov/std/gonorrhea/treatment.htm

STI Screening Under Medicare - AAPC Knowledge Center. (2015, October 16). Retrieved February 12, 2019, from https://www.aapc.com/blog/32415-sti-screening-under-medicare/

Ghassemzadeh, S., & Lew, V. (2019). SOAP Notes. StatPearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482263/