Form 2808 - Sexually Transmitted Diseases 2014 Page 2
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1
2ATTACH PATIENT LABEL HERE
*
14. Physical Examination
Vital Signs, if clinically indicated:
T:___ B/P: ___P____R____
o Oropharynx: no lesions; no erythema;
o Penis: no lesions; no discharge
no tonsillar exudate o abnl:
o abnl: Circumcised: o yes o no
o Scalp, brows, lashes: no nits; no hair loss
o Scrotum: no tenderness; no nodules
o abnl:
o abnl:
Description of discharge (if present):
o Cervical/supraclavicular/axillary/epitr-
o Vulva: no lesions/rashes; no lice/nits
Female Clients
Male Clients
ochlear nodes: no adenopathy o abnl:
o abnl:
Amount:
Odor (with or
Amount:
o Skin: clear; no lesions/rashes
o Vagina: no lesions; no erythema;
without KOH):
o small
o small
o abnl:
no discharge o abnl:
oyes ono
o moderate
o moderate
o Abdomen: no tenderness to palpation; no
o Cervix: no lesions; no erythema;
o large
pH: o≥4.5 o<4.5
o large
rebound tenderness o abnl:
no discharge; no CMT o abnl:
Adheres to vaginal wall: oyes ono
Color (check all
that apply):
o Inguinal nodes: no adenopathy
o Uterus: no enlargement; no tenderness
Color (check all that apply):
o clear
o abnl:
o abnl:
o clear
o yellow
o yellow
o gray/off white
o green
o Pubic area: no lesions/rashes; no lice/nits
o Anus: no lesions
o green
o bloody
o purulent
o abnl:
o abnl:
o purulent
o color of discharge
o other, specify
*Additional Findings:
matches the white swab
______________
15. Laboratory
16. Clinical Impressions/Diagnosis
17. Treatment/Therapy
o Gonorrhea test: o NAAT o culture
o Bacterial vaginosis
o None
o Cervical
o Urethral
o Urine
o Candidal infection
o Reviewed client’s allergy history
o Rectal
o Pharyngeal o Vaginal
o Cervicitis/MPC
o Reviewed client’s pregnancy status
o Chlamydia
o Urethral gram stain:
o Reviewed client’s breastfeeding status
o Epididymitis
o No GNID found o ≥ 5 white cells, no GND
o Gonorrhea
o GNID found
o Extracellular GND only
o Amoxicillin 500 mg PO TID x 7 days
o Herpes - 1st episode or recurrent
o Herpes test: o culture o serology
o Azithromycin 1 gm PO stat x 1
o HIV
o HIV
o Azithromycin 2 gm PO stat x 1
o HPV/Genital warts
o Chlamydia test: o NAAT o other
o NGU
o Benzathine penicillin G 2.4 MU IM
o Cervical o Urethral
o Urine
o Pediculosis pubis
o bilateral gluteal muscles
o Rectal
o Pharyngeal o Vaginal
o PID
o other site
o Syphilis serology
o Scabies
o Ceftriaxone 250 mg IM stat x 1
o Syphilis: o Unknown duration
o Stat RPR: o reactive o non-reactive
o Primary
o Early latent
o Doxycycline 100 mg PO BID x ______ days
o Darkfield: o found o not found
o Secondary o Late latent
o Metronidazole 250 mg PO TID x 7 days
o Wet prep: o clue cells o yeast
o Tinea cruris
o KOH+ o trich
o WBCs _____________
o Metronidazole 500 mg PO BID x 7 days
o Trichomoniasis
o Pap smear: o HPV
o Contact to: ______________________________
o Metronidazole 2 gm PO stat x 1
o Pregnancy test: o positive o negative
o Normal STD Screening, lab tests pending:
o Acyclovir/Valacyclovir/Famciclovir
_________________________________________
o LE (leukoesterase): o positive o negative
______________________________________
o Other __________________________________
o Other: _________________________________
o Cryotherapy
19. Follow-up for Test Results:
18. Instructions/Counseling
o TCA/Podophyllin/Client applied _________
o OTC pediculosis pubis treatment
o Abstain from sex for ____ week(s) and until
o Clinic will call with results only if a test result is
partner is treated
abnormal or requires re-testing
o OTC fungal/yeast treatment
o Use condoms for risk reduction
o Clinic will call with all test results
o Other _____________________________
o RTC if symptoms increase/persist
o Client will call for results
o RTC in _______ (specify days, weeks or months)
o Unique password to obtain test results by phone
o Partner notification discussed:
o Cards given
Date/Signature/Title of person
_______________________________________
o Expedited partner therapy (EPT) # cards ______
administering/dispensing treatment if not
o Preferred phone # to contact client:
o Control measures and counseling
the primary provider
_______________________________________
provided for HIV+
o Medication instructions provided according
o Printed risk reduction/disease information given
o Clinic may leave message at preferred #
to policy
o Client given a list of services provided/tests
o Restrictions for Alcohol Consumption given
o Other
performed
Specify: ______________________________
o Referrals
Notes:
Primary Provider Signature _______________________________________ Co-signature (if applicable) __________________________________________
o Enhanced Role RN
o CNM o NP
o PA
o MD
Time Enhanced Role RN spent with patient: _______ min.= _______ units
DHHS 2808 (Revised Feb 2014)
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