CC: Urinary Discomfort x half day

Subjective:

32 years old female with no significant PMHx presents to clinic today for urinary discomfort. She states she has a burning sensation during the urination since this afternoon. She notices bright red color on the toilet paper and red color of her urine. She has experienced the same symptoms a week ago. She did not take any medication at that time and those symptoms only last one day and then disappeared. She also complains frequency urination. Her LMP is 08/21/2020. Denies abdominal pain, back pain, vaginal discharge, fever, chill, dizziness, N/V/D.

Objectives:

Allergies: Shellfish – Hives

Current Medication: Patient denies pre-existing medications

Vitals:

• BP: 106/70, sitting, left arm
• HR: 73 bpm, regular
• RR: 16 breaths per minute, regular
• O2 Sat: 98%, RA
• T: 98.3 oral
• Ht: 68 in Wt: 150 lbs     BMI: 22.8 kg/m2

Testing

• UA – Nitrites and leukocyte esterase are detected, WBC >60,

Physical Exam

• Gen – Well nourished, well developed female resting in chair, no apparent distress
• ENT – NC/AT, no JVD noted
• Thorax – Symmetric, no retractions
• Lung – CTA b/l, no rhonchi, rales or wheezes noted
• CV – S1S2 distinct, no M/R/G, RRR. No carotid bruits
• Abdomen – Soft, non-tender, non-distended. Bowel sounds normoactive in all four quadrants, no masses to palp, no hepatosplenomegaly.
• Extremities – No clubbing, cyanosis, or edema, radial/DP pulses +2 bilaterally
• MS – Full range of motion throughout, strength 5/5 bilaterally throughout
• Neuro – A&O x 3, no gross motor or sensory deficits, CN II-XII grossly intact

Assessment

32 years old female with no significant PMHx presents for urinary discomfort. History and urinalysis results most consistent with urinary tract infection.

Plan

• Urinalysis done in office
• Rx send to pharmacy: Ciprofloxacin 500 mg oral tablet Q12H x 5 days
• Follow up within 4 days, repeat UA