Subjective. 33 y.o woman presents to your office complaining of 1 day of increased
urinary frequency, dysuria and sensation of incomplete voiding, patient denies any
recent UTI. She is otherwise healthy, takes no medications, and is sexually active,
using spermicide-coated condoms for contraception. She says she does not have
fever, chills, vaginal discharge, or flank pain. Patient denies any vaginal discharges
nor any other discomfort. Sexually active with one partner, no history of sexually
transmitted diseases. LMP 2 weeks ago. Denies any FMH, cigarette or substance
abuse. Patient denies seasonal or drug allergies.
Objective.
Vital Signs: BP 120/80 P 86 R 18 T 97.8 Ht 5’8’’ Wt 145
HEENT:Patient is well nourished, A&OX3, skin is PWD, Head is normacephalic,
atramatic, Pupils Equal Round, React to Light and Accommodation (PERRLA).
Ears, equal size bilaterally, no tenderness on palpation. Ear canals clear bil, TM
pearly gray.
Nose is symmetric, no septal defects noted, pink turbinates, no inflammation nor
discharge noted. No maxillary or frontal sinus tenderness noted.
Lips are moist, no lesions noted, patient is able to move tong in and out, no white
patches or lesion noted. Uvula rises on phonation.
Pink tonsils, no tonsillitis noted, no exudate.
No cervical nodes noted bil. No thyromegaly noted.
Pulmonary: Resonant to percussion throughout. Breath sounds clear anterior and
posterior.
Cardiovascular No adventitious sounds noted. S1-S2 are normal, not diminished, No
murmurs present. Apical rate is regular.
Gastrointestinal: Abdomen, soft, non-tender, bowel sounds noted in all four
quadrants. No hepatosplenomegally noted, no costovertebral angle tenderness
(CVAT). Patient c/o suprapubic tenderness bil on palpation. No cyanosis or edema
noted on the extremities. The remaining exam was normal
Lab: positive rapid UA test
Assessment:
Differential Dx: (Select your differential dx and explain why it is not the dx: Include
ICD10)
Actual Dx: UTI: Include ICD 10- No need to include rationale for the actual Dx.
Plan: ABX, be aware of patient’s LMP in case of pregnancy (complete full course of
treatment). Encourage patient to drink a lot of water, at least 6-8 cups daily. Wear
cotton underwear