- 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
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