Posted: May 16th, 2023

Soap Note. 14 years old female

Soap Note. 14 years old female. Height 157cm Wt: 75kg. V/S: WNL. CBC, CMP, Lipid panel, Thyroid, HbA1c, HIV, STD test done. All results are normal except for STD:

CT r RNA(TMA), Probe: Positive A

This is Chlamydia test!!!

Called pt and pt’s mother to visit the clinic for lab results explanation and treatment

Pls write Chlamydia treatment including education, referral etc

Do not forget the ICD 10 codes and cpt codes

___________________________
SOAP Note:

Subjective:
The patient is a 14-year-old female who presented to the clinic for a follow-up visit regarding her recent laboratory results. The patient’s mother accompanied her. The patient and her mother were informed about the positive Chlamydia test result during a phone call and have come to the clinic to discuss the results, receive education, and initiate treatment.

Objective:

Vital signs: Within normal limits (WNL)
Height: 157cm
Weight: 75kg
Laboratory results:
CBC: Normal
CMP: Normal
Lipid panel: Normal
Thyroid panel: Normal
HbA1c: Normal
HIV test: Negative
STD test (Chlamydia): CT r RNA(TMA), Probe: Positive A
Assessment:
The patient’s Chlamydia test result came back positive.

Plan:

Education:

Explain to the patient and her mother the diagnosis of Chlamydia, its mode of transmission, and the potential complications if left untreated.
Discuss the importance of practicing safe sex, including consistent and correct use of condoms.
Emphasize the significance of notifying sexual partners about the infection to prevent reinfection and the spread of Chlamydia.
Provide information on the potential consequences of untreated Chlamydia, such as pelvic inflammatory disease (PID), infertility, and increased risk of ectopic (sample nursing essay examples by the best nursing assignment writing service) pregnancy.
Educate the patient and her mother about the recommended treatment and its potential side effects.
Treatment:

Prescribe antibiotics to treat Chlamydia. A commonly used regimen is:
Azithromycin 1g orally, as a single dose, OR
Doxycycline 100mg orally twice a day for 7 days (if not pregnant)
Emphasize the importance of completing the full course of antibiotics, even if symptoms resolve before completing the treatment.
Provide instructions regarding any potential drug interactions or side effects of the prescribed antibiotics.
Referral:

Recommend that the patient’s sexual partners also seek medical Assessment and treatment to prevent reinfection and further transmission. Provide information on local clinics or resources that offer confidential testing and treatment for sexually transmitted infections.
Follow-up:

Schedule a follow-up visit in 4 weeks to assess treatment response, reinforce education, and address any concerns or questions.
ICD-10 Codes:

Chlamydial infection: A56.01
Chlamydial cervicitis: N72
CPT Codes:

Office visit: 99213 (for the clinic visit to explain the lab results and provide education)
CT r RNA(TMA), Probe: 87581 (for the Chlamydia test)

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