Lisa is a 19-year-old female who presents to the clinic c/o abnormal vaginal

Lisa is a 19-year-old female who presents to the clinic c/o abnormal vaginal

discharge for one week after having unprotected vaginal intercourse with a new

male partner she has been dating for a couple of weeks. Lisa’s pregnancy test is

negative and her LMP was 2 weeks ago. As her health care provider, you will need

to perform testing to determine if Lisa has contracted a sexually transmitted

infection or other vaginal infection.

Write a brief SOAP note regarding this patient. Make sure to include your answers

to these questions in your SOAP note.

1. Subjective:

a. What other relevant questions should you ask regarding the HPI?

b. What other medical history questions should you ask?

c. What other social history questions should you ask?

2. Objective:

a. Explain what POCT will you order and perform, and discuss your

rationale for ordering and performing each test.

3. Assessment/ Diagnosis:

a. What would be an appropriate diagnosis for her? Why?

b. Any other diagnosis or differential diagnosis you would like to add?

4. Plan:

a. What will you prescribe for this patient? Why? (assume one of your

lab test results is positive), Explain what medications and treatments

you would recommend

b. Explain treatment guidelines and side effects including any possible

side effects of the medication and treatment(s), partner notification,

and follow-up plan of care.

c. What patient education is important to include for this patient?

(Consider when can the patient resume sexual activity)

d. Explain complications that can occur if patient does not comply with

treatment regimen.

APA format