Nurse Practitioner Soap Notes and Genital Infection Order Instructions: see the instruction I sent Nurse Practitioner SOAP Notes

SUBJECTIVE DATA

Chief Complaint (CC): “I have been having vaginal itching, burning and discharge for the past five days now”

History of Present Illness (HPI): Ms. T. A is a 35-year-old African American female who presents to the clinic stating that she has been having vaginal itching, burning and discharges for the past five days now. A patient described that her discharge is thick cottage cheese without any odor. She reported itching and burning with urination. She denies any blood in her urine. She reported itching and burning sensation when urination. She reported pain, burning, and discomfort during sexual intercourse. She rated her pain during urination as 4 and pain during sexual intercourse as 5 on a scale of 1 to 10. She denies using any medications to relieve her symptoms. She denies fever, chills, back pain costovertebral tenderness and suprapubic pain. She denies nausea and vomiting. She denies using a condom for sexual intercourse because is in a monogamous marriage with her husband. She also came to the clinic to have pap/ pelvic examination done.  Her last pap was March 2012. The patient said her menstrual period is regular. Her last menstrual period was April 20^th, 2014. She used about 4 pads a day during her periods. She denies using tampons for her period or douching. Patient’s age of onset of menarche was 12-years-old. She is sexually active. She denies the history of any sexually transmitted disease.

Medications: She is currently taking women’s multivitamin once a day.

Allergies: No known allergies to medications, foods, insects and the environment.

Past Medical History (PMH): No history of past medical history,

Past Surgical History (PSH): No history of past surgical history.

OB/GYN History:

Obstetric History: G2, P0, T2, A0, and L2. She has her two children full term their weights range from 7lbs 8lbs. she has spontaneous vaginal delivery no complications on April, 15^th,  2009 and  July  5^th, 2011.

Her menstrual period is regular and lasts for about 3 days. Method of contraception is ParaGard IUD (10years) which was inserted November 14^th, 2011.

Menstrual History: Age of onset of menarche was12-years-old. Her last menstrual period was

April 20^th, 2014. Her menstrual period is regular and last for about for 4 days. No spotting or bleeding since her last menstrual period. Her last previous pap examination was March 2012 and no history of the previous mammogram. No history of sexual of sexually transmitted diseases. She denies using douching.

Method of Contraception: Method of contraception is ParaGard IUD (10years) which was inserted September 14^th, 2010.

Sexual function: She is sexually active with her husband. Her last sexual activity with her husband was three days ago.

Personal/Social History: She is married and lives in a single-family house with her husband and children.  She graduated with a bachelor of science in biology. She is currently working in a laboratory company as a manager.  She denies exposure any to smoke at home. She does not smoke, drinks alcohol or use illicit drugs.  She sleeps for about 7 hours at night. She has a good family support system. She has one regular sex partner (her husband) and three-lifetime partners. She is sexually active and her form of contraception is ParaGard IUD. She eats healthy food. Her favorite’s foods are baked fish, beans and vegetables. She walks about 2 miles a day. Her hobbies are jogging, cooking and watching movies.

Immunizations: Flu vaccine January 2014, Varicella April 2003, Hep B July 2009, Tdap February 2010, MMR, May 2007 and pneumonia: Never received.

Family History:  Grandparents on both sides are deceased with no medical problem.

Her mother is 55 years alive with no medical problem.

Father: Her father 57 years alive with no medical problem.

Brother: Her brother is 30 years alive with no medical problems.

Sister:  Her sister is 32 years alive with no medical problem.

Nurse Practitioner Soap Notes and Genital Infection Review of Systems

General: She denies any chills or fever, change in appetite, fatigue, and weakness. No recent weight changes.

 Skin: She denies any rashes, sores, lumps, lesions, acne, itching and dryness or changes.

HEENT: She denies dizziness, headache, and syncope. She denies any problem with her hair. No history of alopecia. She denies ear pain, difficulty hearing/ changes in hearing and denies tinnitus. She denies changes or problems in vision. She denies eyes pain, blurred vision, seeing spots, burning, edema and discharge. She denies epistaxis, runny nose, and sinus pain.

Neck: She denies pain or stiffness in moving her neck.

Breast:  She denies breast tenderness, lumps, discharge, and nipples darkening.

Respiratory: She denies any wheezing, coughing or shortness of breath.

Cardiovascular: She denies any chest pain or shortness of breath. She denies any irregular heartbeat.

Gastrointestinal: She denies any abdominal tenderness and pain. Her last bowel movement was yesterday. She denies any changes in bowel or bladder habits. She denies constipation, diarrhea, and blood in the stool.

Peripheral vascular: Pulses are palpable in all extremities. No edema.

Urinary: She reported the frequency with urination, pain and burning upon urination and she rated her pain as 6 on a scale of 1-10.

Genital: She reported cottage cheese-like discharge from the vaginal and burning sensation and frequency with urination. She denies douching or odor from the vagina. She denies any history of abnormal pap or sexually transmitted diseases. She reported soreness and redness to the outer area of the vaginal.

Musculoskeletal: She denies having any muscle weakness and joint pain.

Psychiatric: She denies having any present/past psychiatric problems. No depression, mood changes or anxiety.

Neurological: She is alert and oriented to place, time and person. She denies any recent change in memory or forgetfulness. She denies any tingling, numbness or paresthesia.

Hematologic: She denies any history of blood disorder and easy bruising. She has regular menstrual bleeding.

Endocrine: She denies any history of diabetes or thyroid disorders. No excessive thirst, polyuria, polydipsia, and polyphagia.

 OBJECTIVE DATA:

Vital Signs: BP 120/66, T 98.7, P 80, R 18, and oxygen saturation 98 % on room air. Height 65 inches, weight 145 lbs. and BMI- 23.4.

General: Ms. T. A is a 35-year-old African American woman and she is appearing well. She is awake, alert and oriented times three. She is in no acute distress. She is in good health. She dresses appropriately and hair is well groomed.  She smiles appropriately and seems happy. Her posture is good, gait is steady and she walks very well. No mouth or body odor noted. She speaks very good English. She is very friendly, well behave and very polite.

SKIN: No rashes, lesions, sores, acne, lumps, itching and dryness or changes noted. Good skin turgor.

HEENT:  Pupils equal, round, reactive to light and accommodation. Extraocular muscles are intact. Head is normocephalic. Hair distributions are normal. No ear discharge noted. Nares are patent. Her oral mucosa is normal and appearing well, mucous membranes are moist and pink and good dental hygiene. No teeth missing.

Neck: No thyroid nodules or thyromegaly noted. No jugular vein distention noted.

Breasts: Breasts are bilateral, non-tender to palpation, areolas are light pink and, no palpable nodes and no discharge noted.   No masses, tenderness or lumps noted.  Present of hair around the chest and nipple.

Chest/Lungs:  Chest is symmetrical. Lungs are clear to auscultation in all lobes and percussion bilaterally. No wheezing, rales, rhonchi, or rubs noted.

Heart/Peripheral Vascular: Rhythm and rate are regular. S1 and S2 heard on auscultation and are normal. No S3 or S4 sounds. No murmurs. No edema and pulses are palpable in all extremities. Point of maximum impulse noted at fifth intercostal space. Pulse + 1 in upper and lower extremities. No jugular vein distention noted clubbing, no edema or cyanosis.

Abdomen:  Abdomen is flat no abdominal tenderness and no hepatosplenomegaly on palpation. Bowel sounds were present in all four quadrants.

Genital: Pubic hairs are well distributed on the outer vaginal area. Her cervix is intact and closed os. No lesion or cysts note.  Her uterus is smooth and within normal limits.  Both ovaries are not palpable.  Rectal sphincter muscle was normal. No mass or lesion was noted. Vaginal was reddened and swollen. There was present of the copious amount of cottage cheese like discharge noted from the vaginal canal with no odor.

Musculoskeletal:  Present of adequate muscle tone.  Full active range of motion, no edema noted, capillary refills are less than 2 seconds.  Gaits steady, symmetrical and no edema noted bilaterally. Good muscle tone and bulk are normal. Upper and lower extremities strength are equal throughout bilaterally. Full hip flexion and knee flexion. No involuntary movement noted.

Neurological:  She is alert and oriented to place time and person. She follows command and responds appropriately.

ASSESSMENT:

1) Yeast Infection

Differential Diagnosis:   Chlamydia, Trichomoniasis and bacteria vaginosis

2) Urinary Tract Infection

Differential diagnosis:  Urethritis, vaginal infection (e.g. Gardnerella organisms, candida

albicans, or Trichomonas organisms).

3) Overactive Bladder – UTI, Sphincteric incontinence and neurogenic bladder

EXPLANATION

1. A) Yeast Infections a type of vaginitis that is inflammation of the vagina which is characterized by vaginal irritation, intense itchiness and vaginal discharge. It is caused by fungus candida. A vaginal yeast infection is also called vaginal candidiasis which is very common among women. Three out of 4 women will experience a yeast infection at some point in their lifetimes (Mayo Clinic, 2014). The symptoms of yeast infection can be mild to moderate and include : Thick, white, odor-free vaginal discharge with a cottage cheese appearance, Itching and irritation in the vagina and at the entrance to the vagina (vulva), a burning sensation usually during intercourse or while urinating , redness and swelling of the vulva  and vaginal pain and soreness (Mayo Clinic, 2014). This is my primary diagnosis for this patient based on her physical examination and present illness. T. A complained of complain of cottage cheese like discharge, burning sensation during urination, discomfort and pain during sexual intercourse. During speculum examination, there was present of the copious amount of cottage cheese like discharge noted from vaginal canal and vulva. These are all defining characteristics of yeast infection.
2. B) Urinary Tract Infection: Urinary infection continues to be a major health problem for women worldwide. Bacteria ascend from the colonized urethra into the bladder and continue to ascend into the kidney. If left untreated can cause lasting damage to the kidneys, severe morbidity and even mortality (Shuiling & Likis, 2013). Women are afflicted with UTIs much more often than men because of women’s pelvic anatomy and shorter urethras. The female urethra is short; there is a distance between the urethra and the anus; and the perineal environment is moist, encouraging migration of bacteria from the rectum to the urethra. Women whose mothers have had frequent UTIs also seem to be more susceptible to these infections (Shuiling & Likis, 2013). UTI can be divided in two general classifications: cystitis, a relatively simple infection involving only the urinary bladder and upper tract infection or pyelonephritis, an infection involving one or both kidneys (Shuiling & Likis, 2013). Some women with simple UTI have suprapubic tenderness. Flank pain may be present but usually is not with simple UTI. Its presence would raise the index suspicious for pyelonephritis. Typically, women with pyelonephritis fells acutely ill may have fever, chills or nausea, vomiting and costevertebrate angle tenderness as well as symptoms of cystitis which are dysuria, frequency, urgency and suprapubic pain (Shuiling & Likis, 2013). This patient does not have upper tract infections (pyelonephritis) because she does not have these symptoms. Some of the symptoms of UTI include frequency, burning sensation during urination and cloudy urine. Urine culture is the reference diagnosis of a UTI. A urine dipstick that is positive for leukocyte esterase or nitrite is 75% sensitive and 82% specific for UTI (Shuiling & Likis, 2013). This is my secondary diagnosis for this patient. Based on patient complained of frequency and burning sensation during urination, also her urine dipstick was positive for nitrites, and leukocyte esterase, these are signs and symptoms of urinary tract infection.
3. C) Overactive Bladder: The symptoms of overactive bladder in women include urinary urgency and frequency (Mayo Clinic, 2014). This patient also complained of the frequency with urinary with are symptoms of overactive bladder.

Plan

 Labs:  Urine culture (Mid- stream) was collected and sent to the laboratory. Urine dipstick showed no ketones in urine. There were present of protein, small bilirubin, large nitrites and leukocyte esterase which confirmed that she has urinary tract infection. Pap/pelvic examination- Cervix was swab for HPV, Chlamydia and gonorrhea. She was also screen for cervical cancer. Patient was advised to follow if her symptoms of yeast infections returns or worsens after completion of the prescribed medication because indicate she might need long term treatment regime.

Medications:  She was prescribed nitrofuratoin100mg orally twice daily for 7 days and for yeast infection, she was prescribed Diflucan 150mg orally one dose and dose may be repeat if necessary.

Health Promotion:  The important of completing the treatment regimen even if symptoms resolve before all medications are taken should be emphasized to avoid development of resistant organisms. Most importantly, a woman who has been diagnosed with a UTI should be advised to contact the clinician if her symptoms persist after 48 hours of antibiotic treatment (Shuiling & Likis, 2013).  Patient should be advised to increase fluids intake and avoid delayed in urination. Advised patient to wipe front to back, urinate after sexual intercourse, to wear cotton panties or liners, avoid close fitting clothes, avoid douching both in general and during treatment. Teach patient the important of completing the course of medication. Patient should avoid alcohol consumption when taking metronidazole and for 48 hours after completing the treatment (Tharpe, Farley & Jordan, 2013). Patient was informed that metronidazole can cause nausea, vomiting and cramps even if alcohol is not consumed. In addition, the patient was counselled to avoid intercourse until her symptoms cease and then to use condoms until she completes her treatment (Shuiling & Likis, 2013).  Patient should be encouraged to continue to practice safe sex practice and monogamous relationship, but refrain from sex until symptoms subside. Patient should be advised that if her partner has symptoms of yeast infection, it is important that the partner get treated to prevent reinfecting each other (Shuiling & Likis, 2013).

Disease Prevention: For this patient, Pap smear should be performs according to the recommended guidelines. Patient should be tested for all sexually transmitted diseases based on her history.

REFLECTION:  I learned more about yeast infection. The doctor ordered urine culture (Mid- stream) was collected and sent to the laboratory. Urine dipstick showed no ketones in urine. There were present of protein, small bilirubin, large nitrites and leukocyte esterase which confirmed that she has urinary tract infection. Pap/pelvic examination- Cervix was swab for HPV, Chlamydia and gonorrhea. She was also screen for cervical cancer. She was prescribed nitrofuratoin100mg orally twice daily for 7 days and for yeast infection, she was prescribed Diflucan 150mg orally one dose. Patient was advised to follow if her symptoms of yeast infections returns or worsens after completion of the prescribed medication because indicate she might need long term treatment regime. I agree with Dr. Youssefi treatment plans. In a similar patient evaluation, I would not have anything differently. After the clinical rotation, for that day, my preceptor gave me an assignment to read more about yeast infection and urinary tract infection. . I realized that patient teaching is very important for patient with both yeast infection and urinary tract infection. This is a very interesting clinical experience for me because the patient was diagnosed with both yeast infection and urinary tract infection. Based on my research, I found out that women in professions where frequent urination is impeded have higher rates of UTIs. Nurses, teachers and factory workers where voiding on demand is restricted or difficult are all susceptible to such infections, for example. Education about the need for voiding when the urge is present can decrease the incidence of UTIs in these women. They should also be cautioned against limiting fluids to decrease the need to urinate. Some who have worked under these conditions for a long time will no longer feel a need to urinate until the bladder is already overdistended. For them, timed voiding may be helpful in reestablishing normal bladder responsivity (Shuiling & Likis, 2013).

Nurse Practitioner Soap Notes and Genital Infection Sample Answer

Nurse Practitioner SOAP Notes

Chief Complaint (CC): “In the past 7 days, I have had a very severe pain when urinating and a continuous feeling of scratching my private parts.”

History of present illness (HPI):  A 25 year old female by the name Topyster of Hispania origin comes to the hospital with her hands clinging on her pubic parts as a sign of severe pain. She claims that she has been feeling pain whenever she visits the toilet for a short call and this has been going on for the past one week. The lady reports severe pain while urinating and a feeling of itchiness in her pubic part every minute. She reports that she feels a lot of pain during sexual intercourse and this has caused a lot of discomfort to her partner. Asked whether she has ever used any medication to relieve this pain, she denies, saying that she does not know what type of medicine could help. She reported the pain extending to her periods and it became even worse when using the tampons and pads. The patient reported that she has never used a condom during sexual intercourse because they trust one another. The last menstrual period she received was in September 15^th and during that time, the periods were accompanied with a lot of pain and the blood flow was more than usual.  The patient confirmed that she has never vomited nor felt nausea since the pain started.

Onset	The pain started a week ago, on Wednesday
Location	At the vagina
Duration	When the pain started, it was not very severe; it used to occur after urination. As time went by, it became very severe and a feeling of scratching the vagina ensued.
Characteristics	Sharp pain during urination
Aggravating factors	Urination, sex
Relieving factors	Sleep and cold bath
Treatments/ therapies	Fluconazole, azole medicationhe, butoconazole (Gynazole-1), clotrimazole (Gyne-Lotrimin), miconazole (Monistat 3) and terconazole (Terazol 3).

Medications: the patient confirmed that she has been taking family planning pills.

Allergies: the patient has never experienced any allergy since her childhood, neither food nor environmental allergies reported.

Past Medical History (PMH): The patient confirmed that she has never been to the hospital in the recent past.

Past surgical history: the patient has never undergone any surgery

OB/GYN history:

Obstetric history: she has one kid of 8lbs who she gave birth to on May, 2013 without any complications. The method of the conception of the pregnancy was through sexual intercourse.

Menstrual history:  she started receiving her menstruations while she was 13 years old and the last period she received was on September 15, which lasted for 4 days. She has never used douching.

Sexual function: she is sexually active and the last sexual intercourse was 2 days ago.

Social/ personal history: she is married and they are staying happily together with her husband and their one kid. She graduated from college 3 years ago with a bachelors’ degree in business management. She runs a personal transport business. Her favorite foods are the locally prepared vegetables and sausages. She likes jogging every evening after work. She has one sex partner and has had two sex partners in her lifetime. She has never smoked but she reported taking alcohol when in college, but after marriage, she has never used alcohol.

Immunizations: pneumonia vaccine, January 2013; flu vaccine,e march 2014.

Family history

Grandparents are deceased with a fatal road accident.
Her mother is 47 with no medical problem

Her father deceased in a landslide

Her brother aged 18 is alive and with no medical problem

Her sister is 12 with no medical problem

Review systems:

General: she denies any chills or change in fever and no change in appetite

Skin: she denies skin rashes and skin dryness

HEENT: she denied ear pain, headache, dizziness, blurred vision and seeing spots

Neck: she denies neck pains and difficulty in moving the neck

Breast: she denies breast pain and nipple darkening.

Respiratory: she denies any wheezing and shortness of breath.

Gastrointestinal: she denies of any abdominal pain, constipation, and diarrhea.

Urinary: she reported pain when passing urine, and rated it as 5 in a scale of 1-10

Endocrine: She denies any history of diabetes or thyroid disorders. No excessive thirst, polyuria, polydipsia and polyphagia.

OBJECTIVE DATA:

Vital signs: BP 115/77, T 92, P 60, and oxygen saturation on room air was 96%. Height 54 inches, weight 135 lbs. and BMI- 22.

General:  Topyster is a 25 year old Hispania woman who appears physically well. She is in good health and her hair is well groomed. She smiles appropriately and no odor in mouth or body noted. She speaks very fluent English, polite and well behaved.

SKIN: she has no skin rashes, lesions, nor dryness. In general, she has good skin turgor.

HEENT: the pupils are equal, round and very reactive to light and accommodation. Hair distribution is normal. Nares are patent, moist nose and good dental hygiene.

Breasts: the breasts were steady and no palpable nodes and no discharge noted.

Neck: no thyroid nodules or thyromegaly noted.

Chest/lungs: the chest is symmetrical and lungs are very clear and no wheezing.

Heart/ peripheral vascular: rhythm and arte are regular. No murmors or edema.

Genitals: pubic hair well distributed and her cervix is intact.

Musculoskeletal: the presence of enough muscle tone and no edema noted. Good muscle tone and bulk is normal.

ASSESSMENT:

diagnosis	positives	negatives	Rationale & reference
Yeast infection	Itching in the vaginal area and around the vulva. Burning sensation in the vaginal area Swelling of the vulva White/gray vaginal discharge Pain during sexual intercourse	No headaches No vomiting No fever No chills	Most yeast infections are caused by a type of yeast called candida albicanas (Dupont, et. al., 2009). The bacteria accumulate around the vagina resulting to the multiplicity of the yeast. The symptoms of the yeast infection include: itching in the vagina, burning sensation especially during urination and sexual intercourse, thick white discharge with cheese cottage appearance and swelling of the vulva (Mukherjee, Sheehan & Ghannoum, 2005). These symptoms were confirmed in Topyster and it was made the primary diagnosis.
Genital herpes	Burning sensation during urination	No fever No muscle aches No blister on the vagina No appetite loss	It is a sexually transmitted infection caused by the herpes simplex virus (Barton & Sen, 2007).  The general symptoms include fever, muscle aches in the back, buttocks and thighs. In women, blisters may be around the vagina, cervix or the anus. In men, blisters may be around the pennies, scrotum and around the anus. Pain during urination is common in both genders. (Wald, 2006) In the examination of Topyster, these symptoms were not confirmed and the patient did not complain of any of these.
endometriosis	Pain during urination and sexual intercourse	No abdominal pain or pelvic pain	Endometriosis is the abnormal growth of endometrial cells similar to those that form in the uterus. Its symptoms include painful periods, painful sex, pain in the lower abdomen and pelvic area (Ferrero, et. al, 2011). The patient confirmed pain during sex and urination.

 

Lab test	Patient results	rationale
Urine culture (mid-stream)	No ketones in urine Presence of protein, bilirubin, large nitrites and leucocyte esterase.	Urinary tract infection is an infection that happens anywhere along the urinary tract. Its symptoms include a strong and urgent feeling if urination every time and burning sensation. The patient was advised to visit back the hospital if her symptoms worsened.

 

condition	pharmacological	test	Follow up	rationale
Yeast infection	Nitrofuration in 100mg orally, twice daily for 7 days Diflucan 150mg one dose	Urine test was positive	If symptoms persist patient to visit the hospital after two weeks	The use of nitrofurationin the treatment of yeast prevents other additional infections that may result out of fungal infections.

 

Health promotion: the yeast infection is a fungal disease, which results out of bacterial infection (Mukherjee, Sheehan & Ghannoum, 2005). It is very important that the patient completes her medication even if she feele relieved. This will help prevent the development of other resistant microorganism. The patient is advised to forgo sexual intercourse until after her health has completely improved (Dupont, et. al., 2009). The patients should be advised to ask her husband to visit the hospital because he both has got the yeast infection.

Disease prevention: Pap smear should be performed according to the set standard procedures.  Testing should be carried out on the patient based on his medical history.

Reflection: I have learnt a lot from this study about yeast infection. From the study, it is very evident that observing cleanliness is the very best option of avoiding such medical complications. In order to avoid the yeast infection and other sexually transmitted diseases, it is very important that one observes cleanliness especially on their underpants. There is an urgent need to carry out public education about this sexually transmitted disease in order to avoid the spread of the disease and deal with the disease amicably. If we can carry out public education, then we can reduce the spread of the disease by a very high percentage.  Not all disease symptoms can be confirmed just by asking patient questions. Thorough examination of the patient is very necessary before commencing any treatment. Prescription of antibiotics in the patient’s medication is very necessary as it helps the patient fight against other additional diseases that may arise out of the bacteria that may attack the pubic parts (Soong & Einarson, 2009). Completion of the dose is very necessary as this will help prevent other medical complications that may result out of the same disease.

I feel much touched by the level at which the sexually transmitted diseases are attacking women. In fact, three quarters of the people who report to the hospital about sexually transmitted diseases are women. This shows that there is a very crucial need to help our young ladies in schools and those out of schools by educating them on hygiene best practices.

Nurse Practitioner Soap Notes and Genital Infection References

Barton, S. & Sen, P., 2007. Genital herpes and its management. BMJ. May 19, 2007; 334(7602):

 1048–1052. doi:  10.1136/bmj.39189.504306.55

Dupont, F, Lortholary, o., Ostrosky-Zeichner3, L., et. al., (2009).Treatment of candidemia and

invasive candidiasis in the intensive care unit: post hoc analysis of a randomized,

controlled trial comparing micafungin and liposomal amphotericin B. Critical Care 2009,

 13 (5):R159 (doi:10.1186/cc8117)

Ferrero, S., Camerini, G., et. al (2011). Bowel endometriosis: Recent insights and unsolved

problems. World Journal of  Gastrointestinal Surgery . Mar 27, 2011; 3(3): 31–38. Published online Mar 27, 2011. doi:  10.4240/wjgs.v3.i3.31

Mukherjee, P., Sheehan, D.& Ghannoum, M., (2005). Combination Treatment of Invasive

Fungal Infections. American Society for Microbiology: New York.

Soong, D. & Einarson, A., 2009. Vaginal yeast infections during pregnancy. Canadian Family

Physician. Mar 2009; 55(3): 255–256. College of Family Physicians of Canada. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2654841/#__ffn_sectitle

Wald, A., 2006. Genital HSV‐1 infections. Sex transmission infection v. 82(3); 2006 June.

doi:  10.1136/sti.2006.019935