Chief Complaint: “pain with urination”
History of present illness: 35-year-old female patient presents to clinic today for “pain with
urination”
... [Show More] that started three days ago. Patient denies frequency but doesfeel the urgent need
to urinate and “some slight burning.” She denies any foul odor. Denies fever, chills, N/V/D.
Patient stated that she has attempted to increase her fluid intake and used OTC Azo for pain
management.
Past Medical History: Kidney stones (2008), Appendicitis (2012)
Surgical History: Lithotripsy with stone removal & ureteral stent placement (2008),
Appendectomy (2012), Right clavicle fracture (2019)
Family History:
• Mother: Age 60, Hypertension, depression
• Father: Age 62, Diabetes Type 2, obesity, CAD, MI, cardiac stents x2.
• Siblings:
o Brother (Andrew, 31): No medical history orsurgeries.
• Maternal Grandmother: Age, 79, Hypertension
• Maternal Grandfather: Deceased at age 79, Stroke, hypertension
Paternal Grandmother: Age 81, Breast cancer, osteoporosis
• Paternal Grandfather: Deceased at age 77, CAD, MI, diabetestype 2, hypertension
Social History:
• Married, 1 child (son, age 9), sexually active with spouse only. Heterosexual.
• Employment: 4
th grade teacher, currently enrolled in master’s degree program
• Health Exams:
o Medical exam-reported last physical wasin March, states “I get them around my
birthday every year.”
o Dental exam-reports an upcoming cleaning appointment. Last dental exam was
completed around 6 months ago.
o Vision exam-recently got annual exam eye due to needing replacement contacts.
States “I go every year so that I can make sure I have the correct prescription for
my contacts and glasses.”
• Religion: Christian, active in church every week on Sunday
• Caffeine Use: 1 coffee in the morning, sometimes a soda at lunch (soda-3 a week)
• Tobacco Use: Neversmoker
• Alcohol: socially-reporting 6-8 drinks a month
• Illicit Drugs: Denies
• Exercise: reporting exercising 3-5 times a week
• Seatbelt: wears 100% of the time
• Sun Exposure: reporting “average sun exposure but usessunscreen when outside.”
Allergies: NKDA, denies allergies to latex or food. [Show Less]