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Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals and other team members needed to complete patient care.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.
CASE SCENARIO: Emily, an 18-year-old female presents with complaints of “problems with her birth control.” She was evaluated last month for a well-woman exam and was placed on Ortho Tri-Cyclen LO. Since then, she experienced spotting for one week prior to the “white pills” and then had her period. She also complains of a foul-smelling discharge that she has noticed for the past few days. She is requesting to change her pills and requests “something for this discharge.” Her pelvic exam reveals minimal discharge without odor, cervix bleeds easily to touch, and negative cervical motion tenderness. Her urine pregnancy test is negative and she is positive for gonorrhea and negative for chlamydia.
What is your plan of care for this patient? USING SOAP Note FORMAT
What additional screening tests and patient education would you recommended for this patient?
Please refer to evidence-based guidelines to support your decision-making.