STI Screening

HISTORY:

Presents for routine sexually transmitted infection screening

Current symptoms: ‍none

‍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

‍chills

Last menstrual period: ‍ ‍daysweeksmonths ago



Sexual activity: ‍activeinactive, ‍ partners, ‍menwomenmen and women

Condom use: ‍alwayssometimesnever

History of STIs: ‍none ‍

HPV vaccination: ‍up-to-dateincompleteunvaccinated

Last Pap smear: ‍ ‍monthsyears ago ‍never



Social history:

Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU



EXAM:

General appearance: ‍well-appearing

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

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

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

Pelvic: vulva ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍no cervical motion tenderness

Genital: ‍normal, testicles ‍normal, penis ‍normal



ASSESSMENT:

‍Asymptomatic STI Screening ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍HIV, ‍syphilis, ‍HBsAg, ‍anti-HBs, ‍hepatitis C, ‍HSV, ‍β-HCG

- STI screening: ‍Chlamydia, ‍Gonorrhea, ‍Trichomonas, ‍Herpes Simplex Virus

- Pap smear

- ‍Antibiotics

- ‍Topical treatments

- ‍HPV vaccine

- Sexual partners treatment

- Abstinence until treatment completed and symptoms resolved

- Counseling on condom use

- Referral to gynecologist

- Referral to urologist

- Referral to infectious disease specialist

- Follow-up in ‍ ‍weeksmonths

- Return if symptoms worsen or if new symptoms develop such as fever, abdominal pain, or increased discharge