Urology Case Study

CHART NOTE

Comes in today for exam because of vaginal and perineal burning and itching which began during the night.  When she urinates, she feels burning towards the perineum, but is not certain if it is specifically on it, in addition to a severe burning sensation when the urine hits her labia.  She is having no urinary frequency.

PHYSICAL EXAMINATION

Perineum is very sensitive at the introitus and the labia minora, which are erythematous without discrete lesion.  Palpation of the urethra is extremely painful.  Suprapubic palpation is nontender.

Spun clean-catch urinalysis shows a few wbc’s and a few rbc’s in a very dilute sample.  C&S is sent.

ASSESSMENT

Probable urethritis.

PLAN

Prescription for doxycycline 100 mg p.o. b.i.d. for 10 days is given.

FOOTNOTE

Line 14.  Exam was translated as Examination in the heading.

Line 15.  The comma dictated after introitus was deleted.

Line 19.  White blood cells and red blood cells are written in small caps and plural is written with apostrophe.