Observations: Discharge- yellow, kind of mucousy, kind of creamy some smelly
Skin: Pink, warm, moist
CC: Burning during voiding and vaginal
... [Show More] discharge
HPI (History of Present Illness):
Patient presents with a 2-day history of on urination and urinary frequency. She denies fever, chills,
myalgia etc. She denies any prior history of UTI's, however, does have a new boyfriend and they have
been very sexually active.
PMH (Previous Medical History):
Allergies: NKDA
O t h e r a c t i v e p r o b l e m s : None
M e d i c a l , s u r g i c a l , o b s t e t r i c , h o s p i t a l i z a t i o n s : None
P r e v e n t i v e H e a l t h : Last Pap smear 1 year ago: no Hx of abnormal results
Previous screening for STDs
I m m u n i z a t i o n s : No previous HPV vaccination
General immunization status: the patient thinks she is up to date.
Medications: Oral contraceptive pills (OCP): ethinyl estradiol/drospirenone
Ibuprofen for menstrual cramps
Family History:
Mother: diabetes mellitus (DM)
Father: hypertension (HTN), coronary artery disease (CAD), hyperlipidemia
Older sister: Alive and well
Social History:
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Works as a consultant; travels frequently
Alcohol: 1 to 2 times per week; 4 to 5 drinks per occasion
No other substance use
Previous-smoker status; approximate 2-pack-year Hx
ROS (Review of System):
General / Constitutional: Normal, no complaints
S k i n / B r e a s t : Normal, no complaints
H E E N T & N e c k : Normal, no complaints
C a r d i o v a s c u l a r : Normal, no complaints
R e s p i r a t o r y : Normal, no complaints
A b d o m e n / G a s t r o i n t e s t i n a l :
Normal, no complaints
G e n i t o u r i n a r y : Describes pain with urination and urinary urgency
M u s c u l o s k e l e t a l :
Normal, no complaints
N e u r o l o g i c a l :
Normal, no complaints
A l l e r g i c / I m m u n o l o g i c :
Normal, no complaints
L y m p h a t i c / E n d o c r i n e :
Normal, no complaints
H e m a t o l o g i c :
Normal, no complaints
P s y c h o l o g i c a l :
Normal, no complaints
Vital Signs:
Temp:98.6 FPulse:64, rhythm: regularBP:left: 118/62Respiration:12, effort: unlabored
Physical Exam:
Weight 134.0 pounds
S k i n / B r e a s t : No pallor, jaundice, lesions, rashes
Breasts normal, no nodules or masses
No breast discharge
H E E N T & N e c k :
Normocephalic; atraumatic
PERRLA
Optic fundae: no papilledema or vascular pathology
Sinuses nontender to light percussion
No temporal artery tenderness
Thyroid WNL
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Full cervical-spine ROM
No cervical paraspinal muscular tenderness to palpation
C a r d i o v a s c u l a r : RRR w/o murmur or gallop
R e s p i r a t o r y : Clear bilaterally to auscultation and percussion
A b d o m e n / G a s t r o i n t e s t i n a l :
Soft, non-tender, non-distended.
Normal bowel sounds.
No suprapubic tenderness.
No costovertebral angle tenderness (CVA) tenderness.
G e n i t o u r i n a r y :
No labial ulcerations or lesions.
Vaginal walls pink without excoriations.
Bimanual exam without cervical motion tenderness.
No discharge
M u s c u l o s k e l e t a l : Deferred
N e u r o l o g i c a l : Deferred
A l l e r g i c / I m m u n o l o g i c : Deferred
L y m p h a t i c /E n d o c r i n e : Thyroid normal
Tests:
UA: abnormal, suggestive of UTI
Clean Catch for urine culture obtained - results pending
Management:
1. Patient was started on empiric therapy for UTI with Bactrim
• Suggested she can reduce the symptoms with lots of fluids, particularly cranberry juice
• Sexually related UTI can be reduced in frequency with post-coital urination
• F/U prn [Show Less]