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CASE STUDY: SPIRITUAL ASSESSMENT
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Write My Essay For MeA 15-year old female presents to your clinic with complaints of vaginal discharge. She reports a 3-month history of green vaginal discharge and a recent onset of lower abdominal pain. She reports her last menstrual period was 7-weeks ago. She admits she has been sexually active with 3 male partners in the past 4 months. She has never used any form of protection or contraceptive. She reports she took a home pregnancy test 1 week ago and that it was positive.
Past Health History: No history of health problems.
Surgical History: Appendectomy 7 years old.
Family History: Father with Hypertension. Mother and siblings healthy.
Social History: Lives with parents and one older female sibling in a single-dwelling home. She is a 10th grade student in local high school. She describes herself as a “C-student” and does not participate in any extracurricular school activities or athletics. She reports experimenting with alcohol and cigarettes when she was in junior high school but that “both made her so sick” that she did not continue to use. Denies illicit drug use in the past or present. She reports feeling safe in her home. She’s had an 18-year old boyfriend for the past two months and her parents and she thinks her parents are unaware of her relationship with him. She denies history of emotional, sexual, and physical abuse. She reports she feels safe in her home and when she is with her boyfriend.
Physical exam reveals an afebrile, well-appearing female. Pelvic exam reveals a friable cervix with green discharge from the cervix. There is no cervical motion tenderness. Diagnostics: Urine HCG positive.
Diagnostic Testing: STD testing is positive for chlamydia and negative for N. gonorrhea; rapid plasma regains (RPR) is nonreactive and HIV is negative.
The NP treats the patient with one dose of Azithromycin 1 gram orally in the clinic and counsels the patient of safer sex practices. HIV conversion is also discussed with the patient and she is scheduled to return to the clinic for HIV testing.
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