SOAP Notes Gonorrhea

SOAPNotes: Gonorrhea

SOAPNotes: Gonorrhea

Chiefcomplain (CC):Lower abdominal pain, yellowish vaginal discharge, fever, itchy andred eyes.

Historyof the present illness (HPP):MA is a 24 year-old female who have been in her usual healthcondition until the last 4 days when she started experiencingabdominal pain. She describes the pain as being sharp and severe. Thepain was localized to her lower abdominal regions and was moreintense on her right side. She has been relieving the pain withAdvil, but it worsened the evening before she reported to the clinic.She reported that the pain was accompanied by fever and sweat, whichkept her awake the entire night.

MAis sexually active and has established a relationship with a newpartner, which has lasted for 4 months. She broke up with herprevious partner about one year ago. Her new partner uses condomsirregularly. He gets upset when asked why he does not use condomsregularly and claims that MA does not trust him. She does not use anyother type of contraceptive.

MA’svaginal discharge was yellowing about 11 days ago, but she assumedthat it was as a result of self-medication with OTC Gyn-Lotrimin.

Drug/Medication: Gyn-Lotrimin and Advil

Pastmedical history:She has never been diagnosed with STDs in the past. Had tetanusbooster, but denies diabetes.

Familyhistory:Her sister suffered from an ectopic pregnancy and one cousin wasdiagnosed with STDs.

Socialhistory:MA is a college student who lives in the dorm. She is active inacademic and extra-curricular activities. She has no history ofsubstance abuse and lives in a stable family.

Allergies:No known drug allergies.

Skin:No rashes.

Eyes:Itchy and red.

Respiratory:No respiratory conditions reported.

Musculoskeletal:No musculoskeletal condition reported.

Objectiveassessment (O):

VS:100/68, 102.5, WT 110, HT 5’2”

Heart:S1&gtS2 at pex, pulses 2+/equal bilateral, RRR without murmurs.

Gen:AOX3, she appears moderate, but ill at the moment.

Chest:lungs, clear.

Abdomen:Flat with RLQ scar. Diffusely tender to palpation and markedtenderness to RLQ. No abdominal masses and organomegaly noted. Liverspan: 5 cm RMSL with no splenic dullness at 10 ICS-LAAL, 9 cm RM CL.

Pelvicexamination: External genitalia with normal limits and withoutlesions. A speculum exam indicated that MA released yellow andpurulent discharge. A bimanual examination revealed cervical motiontenderness. In overall, the left abdominal region was unremarkableand non-tender. The uterus was normal sized, retroflexed, andconsistent.

Differentialdiagnosis: From the chief complaints and symptoms expressed by MA,she could be suffering from gonorrhea. Gonorrhea is an STD that ischaracterized by greenish yellow vaginal discharge, lower abdominalpain, swelling of the vulva, conjunctivitis, and burning whenurinating (Walker &amp Sweet, 2011). Some patients may expressfever and pain during sexual intercourse.

Chlamydia:This is also a type of STDs that is characterized by burning duringurination, abdominal pain, abnormal discharge, urinary urgency, andblood in urine (Lanjouw, Ouburg, Vries, Radcliffe &amp Unemo, 2012).The condition should be diagnosed in the earliest time possible toprevent infertility, permanent damage of the fallopian tube, and therisk of ectopic pregnancy (Mishori, McClaskey &amp Winklerprins,2012).

Bacterialvaginosis: This is a type of STI that is characterized by vaginaldischarge and serious vaginal odor (Machado, Castro, Almeida, Cereija&amp Cerca, 2014). It is not a dangerous condition, but it may causedisturbing symptoms.

Assessment:Probable disease is gonorrhea. Knowledge deficits include sexualpractice and GYN care. MA engaged in high risk sexual practices withno immunization hepatitis B.


Thepatient is tested by swabbing the infected sites and identifying thespecific type of bacteria that is responsible for the infection.Procedures that involve bacteria culture may be less effective due tosampling errors. Accurate diagnostic tests to be used include the DNAprobe and amplification techniques, such as PCR.

Afterconfirming the gonorrhea infection, the patient is given acombination of antibiotics, including azithromycin and ceftriaxone(Walker &amp Sweet, 2011). The patient should be advised to undergothe treatment together with the partner. MA will return to the clinicafter two weeks for follow-up.

Patienteducation: Many patients suffer from STDs due to lack of informationabout the possible methods of preventing these diseases. To this end,it will be appropriate to conduct a patient education on MA and her 4months partners on the significance of using protection or beingfaithful to each other. This will prevent chances for the recurrenceof gonorrhea.

Rationale:Gonorrhea is a bacterial infection, which makes antibiotics and mostsuitable pharmaceutical products to use in the case of MA. Inaddition, treating MA and her partner is the only strategy that canbe used to ensure that she does not suffer from re-infection.

Reflectionnotes: Gonorrhea is an STD that can be prevented and treatedeffectively, especially if it is diagnosed at an early stage. Thebest moment experienced when treating MA was when his partner agreedto take part in the treatment process, since this assured me that shecould recover successfully and avoid the risk of re-infection.However, I would recommend a DNA probe soon after suspecting that apatient is suffering from gonorrhea, instead of undergoing thetraditional procedures that are less accurate.


Lanjouw,E., Ouburg, S., Vries, H., Radcliffe, K. &amp Unemo, M. (2012). 2015European guideline on the management of Chlamydia trachomatisinfection. InternationalJournal of STD and AIDs,1, 1-16.

Machado,A., Castro, J., Almeida, C., Cereija, T. &amp Cerca, N. (2014).Diagnosis of bacterial vaginosis by a new multiplex peptide nucleicacid fluorescence in situ hybridization method. PeerJournal,3, 1-12.

Mishori,R., McClaskey, L., &amp Winklerprins, J. (2012). Chlamydiatrachomatis infections: Screening, diagnosis, and management.AmericanFamily Physician,86 (12), 1127-1132.

Walker,K. &amp Sweet, L. (2011). Gonorrhea infection in women: Prevalence,effects, screening, and management. InternationalJournal of Women’s Health,3, 197-206.