• CC: dysuria and urinary frequency
  • HPI: RG is a 30 year old female with increase urinary frequency and dysuria that began 3 days ago. Pain is intermittent and described a burning only in urination, but c/o flank pain since last night. Reports intermittent chills and fever. Used Tylenol for pain with no relief. She rates her pain 6/10 on urination. Reports a similar episode 3 years ago.
  • PMH: UTI 3 years ago
  • PSHx: Hysterectomy at 25 years
  • Medication: Tylenol 1000 mg PO every 6 hours for pain
  • FHx: Mother breast cancer ( alive) Father hypertension (alive)
  • Social: Single, no tobacco , works as a bartender, positive for ETOH
  • Allergies: PCN and Sulfa
  • LMP: N/A

Review of Symptoms:

  • General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
  • Abdominal: Denies nausea and vomiting. No appetite


  • VS: Temp 100.9; BP: 136/80; RR 18; HT 6’.0”; WT 135lbs
  • Abdominal: Bowel sounds present x 4. Palpation pain in both lower quadrants. CVA tenderness
  • Diagnostics: Urine specimen collected, STD testing


  • UTI
  • STD

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