Urology Case Study

CHART NOTE

SUBJECTIVE

This is a 24-year-old white married female who complains of urinary burning and frequency beginning approximately 5 days ago.  She denies any prior urinary problems.  She has had no chills, fever, flank pain, or hematuria.  She has noted nocturia x3 since the onset of her symptoms.  She has had no nausea or abdominal pain.  She denies vaginal discharge or itching.  Last menstrual period began 17 days ago.  She is on Demulen 1/35-28 for birth control, but has taken no other medicines.  She is sexually active in a stable and apparently exclusive marital relationship.  Her general health is good, and she denies recent URI (upper respiratory infection).  She has never been pregnant.

OBJECTIVE

Temperature 98.6, pulse 72 and regular, blood pressure 116/80.  Patient is alert and in no distress.  Her skin is pale, warm, and dry.  There is no costovertebral angle tenderness, and palpation of the abdomen indicates no masses or organomegaly.  The bladder is not palpable or tender.  On pelvic examination, there is no evidence of vulvar edema or erythema and no discharge.  The cervix is clean, and only scant mucoid material is seen in the vault.  She had a negative (class 1) Pap smear about 8 months ago.  Bimanual examination reveals a normal-size uterus which is slightly retroflexed.  The adnexal areas are normal.  There are no masses or abnormal tenderness, and the rectal examination is negative.

A clean-voided urine shows 15 to 20 white blood cells per
high-power field, 8 to 10 red cells, 4+ occult blood, 1+ protein, negative for sugar, pH 5.5.

ASSESSMENT

Acute cystitis.

PLAN

1. Septra DS 1 b.i.d. x7 days.

2. Pyridium 200 mg q.4-6h. p.r.n. for burning.

3. Increase oral fluids.

4. I discussed the probable origin of her condition with the patient and advised her to make a practice of voiding immediately after intercourse in future.

5. Patient is to report back in 1 week for repeat urinalysis and to see me, and to call in the day after tomorrow if she has any persisting symptoms.

FOOTNOTE

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Line 34 (Page 1).  Alternative:  15-20.

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