Chlamydia

HISTORY:

‍Symptoms suggestive of a STIUrethral dischargeVaginal discharge for ‍ ‍hoursdays

‍vaginal discharge, ‍clear, ‍thin

‍fishy smell

‍penile discharge

‍burning on urination

‍genital itching

‍genital irritation

‍scrotal pain

‍lower abdominal pain

‍pelvic pain

‍rectal pain

‍bleeding between periods

‍bleeding after intercourse

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

Treatments tried: ‍none, ‍effectiveineffective



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Genital: ‍normal, testicles ‍normal, penis ‍normal

Pelvic:

- External genitalia: ‍normal, ‍inguinal lymphadenopathy

- Vagina: ‍normal, discharge ‍normal, ‍malodorous

- Cervix: ‍normal

- Uterus: ‍normal, ‍no cervical motion tenderness

- Adnexa: -R ‍normal, -L ‍normal

- Tests performed: ‍Pap test, ‍HPV DNA, ‍vaginal culture, ‍chlamydia/gonorrhea, vaginal pH ‍< 4.5> 4.5, whiff test with KOH ‍negative

- Performed with chaperone



ASSESSMENT:

‍Chlamydia ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Urinalysis

- Urine culture

- STI screening for chlamydia and gonorrhea

- Blood work: ‍HIV, ‍Syphilis, ‍Hepatitis B, ‍Hepatitis C

- Pap smear

- ‍Antibiotics (vary depending on local resistance patterns)

- Sexual partners treatment

- Abstinence until treatment completed and symptoms resolved

- Counseling on condom use

- Referral to gynecologist

- Referral to urologist

- Repeat testing in 3 months

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or do not resolve 1 week after treatment