Final answer:
A sample Gynecology SOAP note for Nadia includes symptoms of vaginal discharge and discomfort, physical examination, a likely diagnosis of a yeast infection, and a plan that involves prescribing medication, recommending STI testing, and providing patient education on sexual health.
Step-by-step explanation:
Subjective: Nadia, a 26-year-old graduate student, presents with symptoms of unusual vaginal discharge, itching, and discomfort. She is concerned about the possibility of an STI due to uncertainty about her spouse's sexual history.
Objective: Physical exam confirms a vaginal discharge without signs of trauma or lesions. No foul odor present. Vital signs are within normal limits.
Assessment: Likely diagnosis is a yeast infection; however, STI screening recommended based on patient's history and concerns.
Plan: Prescribe antifungal medication for yeast infection. Educate patient on the importance of STI testing, safe sex practices, and communication within relationships about sexual history. Schedule follow-up for test results and symptom review.
Patient Education: Discussed with Nadia the nature of yeast infections, causes, and treatment options. Emphasized the significance of STD testing for her and her spouse. Encouraged open discussion with her spouse about sexual health to ensure mutual safety and well-being.