case study
STI
Due: Saturday, 4/26
Patient
B.G. is a 22-year-old Caucasian female presenting with a 1-week history of painful genital sores. She reports a burning sensation with urination and notes the presence of multiple small blisters on her vulva that ruptured into ulcers. She denies any prior episodes of similar symptoms. She also reports low-grade fever and general malaise. Associated symptoms: Dysuria, Itching, Tingling sensation before the appearance of sores, No vaginal discharge.
instructions
· Please complete STI SOAP Note precisely like the SOAP note you completed earlier for me in Asthma.
· Must have a primary diagnosis and three differential diagnoses
· Every idea is cited and referenced with literature within 5 years
· Must have the Medication the patient is taking, Allergies. Social history, Sexual history, family history
· Must have a review of systems
· Physical examination
· Diagnostic studies
· Treatment
· Patient education
· Follow up
· Must be in a basic Microsoft Word document
· APA format.
References reachable and within 5 years
Sample Note – Please follow this exact to complete
ID: D. K is a 70-year-old African American female, born on 06/10/1969, who presents to the clinic for a follow-up and laboratory review. The patient is accompanied by her husband, and she is a reliable source of information.
Subjective:
CC: “I feel tired all the time, and I have had increased thirst and urination in the past three months.”
HPI:
D.K. is a 70-year-old African American female who presents for follow-up for lab review and management of symptoms of polydipsia, polyuria, and fatigue and a possible diagnosis of type 2 diabetes mellitus. The patient reported experiencing increased thirst, increased hunger, urinary frequency, and fatigue in the past three months. D. K thought it was due to her consumption of cucumber, which she had just started consuming, but decided to seek help when she observed occasional blurred vision. She has also noted a 6-pound weight loss in these in these months. The patient’s fasting blood glucose level last visit was 150mg/dl, and HbA1c was 7.5%, which led to a diagnosis of type 2 diabetes mellitus. D.K. has a family history of diabetes, and she is currently not on any diabetes medication. She is following up for lab review and management. The last dental examination was on February 23rd, 2024. The last eye exam was on August 1st, 2023.
Past Medical History: Denies any past medical history.
Hospitalization / Surgical:
Denies past or current
surgeries/hospitalizations since the last visit
Allergies:
Denies drug allergies.
Denies food allergies
Denies seasonal allergies
Medications:
1. Melatonin for Insomnia for sleep
2. Ibuprofen 200mg, 8 hours by mouth as needed for aches and pain
3. Centrum Multivitamin 1 tablet by mouth daily
4. Denies any prescription medication
Vaccinations:
· All childhood vaccines are current
· Last flu shot 09/15/ 2024.
· Covid Vaccines 01/14/2023, Covid Booster 03/15/2023
LMP: The patient is post-menopausal
Family History:
The patient’s mother is 74 years old – with a history of type 2 diabetes and hypertension (HTN)
Father is 76 years old – Osteoarthritis
Sister is 54 years old – No history
Maternal Grandma deceased at age 72 years – Diabetes, Neuropathy, HTN
Maternal Grandfather deceased at age 78 years – Congestive heart failure (CHF)
Paternal Grandmother is 80 years old and living – HTN
Paternal Grandfather died at 64 years – Basal cell carcinoma, Seasonal allergies
Social History:
·
Tobacco: Denies tobacco, illicit drugs, and e-cigarette use.
·
Alcohol: Drinks alcohol occasionally. The last drink was February 10th, 2025
·
Marital History: Lives with husband
·
Occupation: Social worker
·
Sleep/Stress: Denies stress at home and work. Sleeps well
·
Exercise/Diet: Eats a regular diet
·
Safety: Uses seat belts in vehicles and does not own a gun.
·
Hobbies: Swimming, reading
·
Spiritual affiliation: Denies any affiliation
Sexual History:
· D. K. has one sexual partner
· she
is
sexually active
· She prefers males
·
D. K.
denies sexually transmitted diseases (STIs)
· She does not use any form of protection
· Patient has no plans for pregnancy.
Review of Systems (ROS)
·
General: D. K. reports 6lbs weight loss, weakness, and fatigue,
denies fever and chills
·
Eyes: Reports occasional blurred vision, denies pain, redness, and eye tearing,
·
Ears/ Nose/Throat/mouth: Denies difficulty hearing, ringing in the ear, ear pain, or drainage. Denies sinus pain or epistaxis. Denies sore throat or hoarse voice. Denies bleeding gum and dry mouth. Reports last dental exam was on September 2024.
·
Cardiovascular: Denies chest pain or palpitations.
·
Pulmonary: Denies cough, hemoptysis, difficulty breathing, wheezing or chest tightness
·
Gastrointestinal: Denies nausea and vomiting.
·
Genitourinary: Denies difficulty passing Urine, blood in urine, urgency and frequency
·
Musculoskeletal: Denies joint pain and stiffness
·
Endocrine: Denies hot or cold intolerance, polyurea, polydipsia and polyphagia.
·
Integumentary: Denies any rash, masses and wounds
·
Neurological: Denies headache, dizziness, numbness and tingling
·
Lymphatic: Denies feeling any swollen lymph nodes in the neck.
·
Allergy: Denies seasonal or environmental allergies
,
·
Hematologic/lymphatic: Denies abnormal, anemia and easy bruising
·
Infectious diseases: Denies history of infectious diseases
·
Cancer: Denies history of colon or lung cancer
·
Psychiatric: Denies
depression,
anxiety, and
suicidal ideation
Objective
Vital Sign: Temperature: 97.9 F
Pulse: 82
Respirations: 18
BP: 128/77
O2 sat: 100% on room air
Pain Scale: 0/10
Weight: 210lb, Ht: 65in, BMI: 34.9
Physical Exam
General Survey: Patient is pleasant, well groomed, and in no acute distress
Laboratory results: HbA1c 7.5%, fasting blood glucose 150mg/dL, Lipid level
HEENT:
Head: Atraumatic, symmetric scalp, hair has equal distribution and full thickness, no rashes
Eyes: Sclera is white PERRLA, red reflex present, cup to disc ratio 1:3
Ear: The ear canal is moist, the tympanic membrane is pearly grey and intact, no discharge
Nose: Nasal mucosa is pink and moist, no discharge, no septum deviation
Mouth/Throat: Mucous membrane is pink and moist, and tonsils are midline. No palpable mass or lymph node.
Skin: Normal for ethnicity, smooth, warm, and dry. Good skin turgor, no lesions, rashes, ecchymosis, or moles. Nails are without clubbing or cyanosis.
Neurology: Alert and oriented to person, place, and time. The patient is appropriate and answering questions well.
Cardiovascular: Regular rate and rhythm. S1 S2, no clicks, heaves, thrills, or murmurs.
Pulmonary: Chest is symmetric with bilateral expansion. Respirations are even and unlabored. Lung sounds are clear, with no accessory muscle use and no nasal flaring. Lung sounds are clear bilaterally in all fields.
Gastrointestinal: Active bowel sounds in all quadrants, no palpable masses
Genitourinary: No bladder distention noted
Psychiatric: Behavior
is age-appropriate, no anxiety or depression noted
Assessment
Diagnosis
1.
Adult Type 2 Diabetes Mellitus (ICD-10: E11.9)
Diabetes results when the pancreas produces insulin that is not enough for the body’s metabolism and when the body is not able to use available insulin. Diabetes is a chronic disease that leads to hypercalcemia, and uncontrolled diabetes causes problems to the body system, especially the nerves and blood vessels. Symptoms of diabetes include Polydipsia, which is excessive thirst, polyuria which is frequent urination, unintentional weight loss, feeling fatigued or tired, and blurred vision (WHO, 2024). These correlate with D. K’s symptoms at the time.
Differential Diagnosis
2.
Metabolic syndrome (ICD-10: E88.810)
Metabolic syndrome consists of metabolic abnormalities, including central obesity, insulin resistance, hypertension, and dyslipidemia, which are risk factors leading to atherosclerosis, cardiovascular disease, and type diabetes mellitus. Metabolic syndrome is diagnosed in the presence of three or more metabolic abnormalities. This diagnosis is ruled out due to the patient’s normal blood pressure (Swarup et al., 2024).
3.
Drug-Induced Diabetes (ICD-10: E09.65)
Drug-induced diabetes mellitus occurs as a result of the use of a particular medication. It is a form of secondary diabetes that may be reversible when the use of the medication is discontinued, or diabetes may become permanent. The use of drugs such as corticosteroids, Betablockers, thiazide diuretics, antipsychotics, and statins can lead to drug-induced diabetes (Diabetes.co.uk, 2023). This condition is ruled out because D. K. is not on any of these medications.
4.
Hyperthyroidism (ICD10: E03.9)
When the thyroid gland secretes excessive thyroid hormone, it is known as hyperthyroidism. Hyperthyroidism is more prevalent in women over 60 years of age. Risk factors include a family history of thyroid disease, pernicious anemia, and primary adrenal insufficiency. Symptoms are weight loss regardless of increased appetite, rapid or irregular heart rate, and irritability (NIH, 2025). Hyperthyroidism is ruled out due to the patient’s age of less than 60 years, no complaints of irritability, and no family history of the disease.
Plan:
· A lipid panel is drawn to measure the patient’s cholesterol levels which should managed with statins if levels are high (ADA, 2023).
· Thorough foot exam to assess for diabetic neuropathy, foot ulcers, and eye examination for diabetic retinopathy.
Patient results: Hemoglobin AIC is 7.5%, Total cholesterol 210, BP 128/77
Treatment
· Patient is prescribed Metformin 500mg by mouth daily for elevated blood glucose.
· 80mg of Atorvastatin by mouth daily for elevated cholesterol
Education
· Patient education is focused on home blood glucose self-monitoring according to ADA (2023).
· Patient teaching about Hyperglycemia and hypoglycemia (ADA, 2023)
· Emphasizing the importance of lifestyle modification, including eating a healthy diet low in carbohydrates and a regular aerobic exercise regimen of 150 minutes every week (ADA, 2023).
· Importance of medication adherence (ADA, 2023).
· Daily foot inspection (ADA, 2023)
· Yearly eye exam (ADA, 2023)
Follow Up
Follow up with NP in two weeks to evaluate medication treatment with lifestyle changes. Medication adjustment will be required for blood glucose above the recommended level (ADA, 2023).
References
American Diabetes Association (ADA) (2023). Standards of medical care in diabetes
2023.
Diabetes Care,
46(1), S1–S150.
Diabetes.co.uk. (2023). Drug induced diabetes.
Swarup, s., Ahmed, I., Grigorova, Y., & Zeltser, R. (2024). Metabolic syndrome.
In StatPearls. Treasure Island, (FL).
Https://www.ncbi.nlm.nih.gov/books/NBK
World Health Organization (WHO). (2024). Diabetes.
Www.who.int/news-room/fac
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