[##-year-old] female presents with [report of sexual contact with
reported sexually transmitted infection (STI)/complaint] with history and exam
consistent with [specify STI/indications for prophylactic treatment].
Initial considerations in
this patient included gonorrhea, chlamydia, syphilis, human immunodeficiency
virus (HIV), pelvic inflammatory disease (PID), tubo-ovarian abscess (TOA),
pelvic inflammatory disease, genital herpes, and other urinary tract infections
(UTI) amongst others.
Patient presents
[with/without] report of [a sexual partner with a confirmed diagnosis of
gonorrhea/chlamydia/a concerning sexual encounter with unprotected
intercourse]. Patient [reports/denies]
current symptoms [dysuria/frequency/other].
Testing for gonorrhea and chlamydia was sent on a [urinalysis/cervical
swab] obtained in the ED with discussion of appropriate follow up as these
tests will not result for several days.
Patient noted to have a negative urine pregnancy test in the ED. Urinalysis was obtained [with/without]
findings suggestive of UTI [additional].
A genital exam was performed [with/without] evidence of vesicular
lesions [and/or] other symptoms suggestive of herpes genitalis. In addition, the patient was noted to have no
evidence of chancre on genital exam making syphilis unlikely. A pregnancy test was obtained in the ED and
noted to be [positive/negative]. Doubt
PID or TOA at this time given the absence of fever, pelvic pain, purulent
vaginal discharge, or other suggestive findings. After discussion of the risks, benefits, and
alternatives to prophylactic treatment with antibiotics in the ED, the patient
opted to [start treatment in the ED/defer until results of testing and follow
up with his primary care doctor].
We discussed limitations of
STI testing in the ED, and recommended close follow up with his primary care
physician for additional testing to include consideration of HIV testing, and
the patient demonstrated understanding and agreement with this plan.
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