Julianna Mirabelle – I-Human
Patient and Encounter
● Patient: Julianna Mirabelle
● Reason for encounter: Evaluation of possible sexually transmitted infection
● Primary concern: Symptoms concerning for chlamydial infection
● Setting: Outpatient/primary-care or sexual-health clinic
● Relevant history: Sexual-health evaluation with concern for STI exposure/infection
History
General
● How can I help you today?
● What symptoms are you experiencing?
● When did your symptoms begin?
● Have your symptoms been getting better or worse?
● Have you had similar symptoms previously?
● Have you been diagnosed with an STI in the past?
Genitourinary
● Are you experiencing vaginal discharge?
● What color is the discharge?
● What is the consistency or odor of the discharge?
● Are you having vaginal itching or irritation?
● Are you experiencing pain or burning with urination?
● Are you urinating more frequently?
● Are you experiencing pelvic or lower abdominal pain?
● Are you having pain during intercourse?
● Have you noticed any vaginal bleeding?
● Have you had bleeding after intercourse?
● When was your last menstrual period?
● Could you be pregnant?
Sexual History
● Are you currently sexually active?
● How many sexual partners have you had recently?
● Are your partners male, female, or both?
● Do you have a new sexual partner?
● When was your last sexual encounter?
● Do you use condoms consistently?
Patient and Encounter
● Patient: Julianna Mirabelle
● Reason for encounter: Evaluation of possible sexually transmitted infection
● Primary concern: Symptoms concerning for chlamydial infection
● Setting: Outpatient/primary-care or sexual-health clinic
● Relevant history: Sexual-health evaluation with concern for STI exposure/infection
History
General
● How can I help you today?
● What symptoms are you experiencing?
● When did your symptoms begin?
● Have your symptoms been getting better or worse?
● Have you had similar symptoms previously?
● Have you been diagnosed with an STI in the past?
Genitourinary
● Are you experiencing vaginal discharge?
● What color is the discharge?
● What is the consistency or odor of the discharge?
● Are you having vaginal itching or irritation?
● Are you experiencing pain or burning with urination?
● Are you urinating more frequently?
● Are you experiencing pelvic or lower abdominal pain?
● Are you having pain during intercourse?
● Have you noticed any vaginal bleeding?
● Have you had bleeding after intercourse?
● When was your last menstrual period?
● Could you be pregnant?
Sexual History
● Are you currently sexually active?
● How many sexual partners have you had recently?
● Are your partners male, female, or both?
● Do you have a new sexual partner?
● When was your last sexual encounter?
● Do you use condoms consistently?
