Identify the categories of the health history that have been addressed and those for which additional data must be obtained.

K.M. is a 21-year-old Caucasian woman who is seen at the outpatient clinic with complaints of purulent yellow-white discharge and frequent urination over the past 2 weeks. She is sexually active with a new partner.

Subjective data:

Her sexual partner does not use a condom or spermicidal with intercourse
Her last menstrual period was 2 weeks ago
Her sexual partner was recently treated for epididymitis
Appears very anxious
Objective data:

Cervical ectopy noted during Pap test
Mucopurulent cervical discharge
Urine pregnancy test is negative
Nucleic acid amplification test is positive for Neisseria gonorrhoeae and Chlamydia trachomatis

Discussion and answer each of the following Questions:

1. Identify the categories of the health history that have been addressed and those for which additional data must be obtained.

2. What were K.M.s risk factors for acquiring gonorrhea and chlamydial infections?

3. What impact is her diagnosis likely to have on K.M.s self-image? On her relationship with her sexual partner?

4. Discuss the developmental (physical, cognitive, psychosocial and behavioral), age, socioeconomic and cross-cultural considerations that should be considered during the gathering of subjective and objective data and the provision of health care?

5. Relate expected (normal) findings to those described for this patient and discuss any additional information that might be needed before a diagnosis can be made?

6. Based on the assessment data presented, what are the health issues? Provide rationale.

7. Discuss the developmental (physical, cognitive, psychosocial and behavioral), age, socioeconomic and cross-cultural considerations that should be considered during the gathering of subjective and objective data and the provision of health care for this patient.

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