Primary clinic with symptoms of STI and is diagnosed with Gonorrhea

Full Answer Section

• • Hospitalizations: None.
• Medications: None.
• Allergies: No known drug allergies (NKDA).
• Social History (SH):
  • Lives with parents.
  • Attends high school.
  • Sexually active: Yes. Reports one recent new partner. Uses condoms inconsistently. No history of prior STIs. Denies IV drug use.
  • Tobacco/Alcohol/Illicit Drugs: Denies tobacco and illicit drug use. Reports occasional alcohol use at parties.
• Family History (FH): Non-contributory for STIs or chronic medical conditions.
• Review of Systems (ROS):
  • Constitutional: Denies fever, chills, fatigue, weight changes.
  • Genitourinary: Reports dysuria, yellowish-green penile discharge. Denies hematuria, urinary frequency, urgency, hesitancy, nocturia, testicular pain, scrotal swelling, or lesions.
  • Integumentary: Denies rashes, lesions, itching.
  • Musculoskeletal: Denies joint pain, muscle aches.
  • Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation, abdominal pain.
  • Psychiatric: Denies anxiety, depression, suicidal ideation.

O - Objective

• Vital Signs (VS):
  • Temp: 98.6°F (37.0°C)
  • BP: 118/72 mmHg
  • HR: 78 bpm
  • RR: 16 bpm
  • Height: [e.g., 5'9"]
  • Weight: [e.g., 160 lbs]
  • BMI: [e.g., 23.6 kg/m²]
• General Appearance: Well-developed, well-nourished African American male, appears stated age, alert and cooperative, in no acute distress.
• Genitourinary (GU) Exam:
  • External Genitalia: Circumcised. No lesions, ulcers, or rashes noted on penis or scrotum. Testicles descended bilaterally, non-tender.
  • Urethral Meatus: Erythematous with copious yellowish-green purulent discharge noted.
  • No inguinal lymphadenopathy.
• Labs/Diagnostics (Ordered at visit):
  • NAAT (Nucleic Acid Amplification Test) for Neisseria gonorrhoeae and Chlamydia trachomatis from first-catch urine sample.
  • Rapid Plasma Reagin (RPR) for Syphilis (baseline).
  • HIV antibody test (discussed and consented).
• Labs/Diagnostics (Results confirmed after visit):
  • Urine NAAT for Neisseria gonorrhoeae: POSITIVE
  • Urine NAAT for Chlamydia trachomatis: NEGATIVE
  • RPR: Negative
  • HIV Antibody Test: Negative

A - Assessment

• Primary Diagnosis:
  • A54.00 - Gonococcal infection of lower genitourinary tract, unspecified. (Gonorrhea, Urethritis)
• Differential Diagnoses (Considered and ruled out/less likely):
  • Chlamydia urethritis (ruled out by negative NAAT)
  • Non-gonococcal, non-chlamydial urethritis (e.g., Mycoplasma genitalium, Ureaplasma urealyticum)
  • Urinary Tract Infection (less likely given purulent discharge, but considered)
  • Herpes simplex virus (ruled out by absence of vesicular lesions)
  • Trichomoniasis (less common in males, but possible)

P - Plan

• Medications:
  • Ceftriaxone 500 mg IM x 1 dose (for uncomplicated gonococcal infection).
  • Doxycycline 100 mg orally twice daily for 7 days (to cover for possible co-infection with Chlamydia given risk factors, even with initial negative test, or other non-gonococcal urethritis, as per CDC guidelines).
• Patient Education:
  • Discussed diagnosis of Gonorrhea, its transmission, and the importance of full course of medication.
  • Emphasized the need for abstinence from sexual intercourse for 7 days after treatment initiation AND until all partners are treated and symptoms resolve.
  • Reviewed safe sex practices, including consistent and correct condom use to prevent future STIs.
  • Advised on the importance of partner notification and treatment to prevent reinfection and further spread. Provided resources for partner services if needed.
  • Discussed potential for re-testing for cure (test-of-cure) in 3 months per CDC guidelines due to age and risk factors.
  • Provided CDC STI fact sheets.
• Follow-up:
  • Advised to return to clinic if symptoms do not improve within 3-5 days or worsen.
  • Recommended repeat STI screening in 3 months for Gonorrhea, Chlamydia, Syphilis, and HIV due to ongoing risk factors and CDC recommendations for adolescents.
  • Discussed importance of annual STI screening for sexually active adolescents.

Sample Answer

Here is the content for a hypothetical SOAP note for the scenario you described:

SOAP Note Content

Date: [Current Date, e.g., June 26, 2025] Time: [Time of encounter, e.g., 10:30 AM] Patient Name: [Fictional Patient Name, e.g., J.D.] DOB: [Fictional DOB, e.g., 08/15/2007] Age: 17 years old Gender: Male Race/Ethnicity: African American

S - Subjective

• Chief Complaint (CC): "Pain when I pee and discharge from my penis."
• History of Present Illness (HPI): J.D. is a 17-year-old African American male presenting to the primary care clinic with a 3-day history of dysuria and penile discharge. He describes the discharge as yellowish-green and occasional. He denies fever, chills, testicular pain, rash, or joint pain. He reports unprotected sexual intercourse with a new partner approximately 1 week ago. This is his first experience with these symptoms. He denies any recent urinary tract infections or kidney stones.
• Past Medical History (PMH):
  • No known chronic medical conditions.
  • Immunizations: Up to date per school requirements.
  • Surgeries: None.