Chlamydia
Age: years old
Gender:
HISTORY:
Presents with a - history of
Symptoms include:
, , , fishy odor
, up to °, over
Alleviating factors: ,
Contributing factors:
no history of: , , ,
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Abdomen: , , , , bowel sounds , ,
Genital: penis , testes and epididymis ,
Pelvic:
- External genitalia: , ,
- Vagina: , , discharge ,
- Cervix: , ,
- Bimanual exam: , uterus , adnexa ,
- Tests performed: , , pH , KOH sniff test
-
ASSESSMENT:
DDx: chlamydia, gonorrhea, syphilis, HSV infection, trichomoniasis, bacterial vaginosis, yeast infection, mycoplasma genitalium infection, ureaplasma urealyticum infection, HIV, hepatitis B and C, HPV, molluscum contagiosum, pelvic inflammatory disease, epididymitis, prostatitis, cystitis, pyelonephritis
PLAN:
Investigations:
- Urinalysis
- Urine culture
- STI screening for chlamydia and gonorrhea
- Blood work: , , ,
- Pap smear
Treatments:
- (vary depending on local resistance patterns)
- Sexual partners treatment
- Abstinence until treatment completed and symptoms resolved
- Counseling on condom use
Further care:
- Referral to gynecologist
- Referral to urologist
- Repeat testing in 3 months
- Follow-up in
- Return if symptoms worsen or do not resolve 1 week after treatment
HISTORY: EXAM: Pelvic: ASSESSMENT: PLAN: