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.
1 comments:
Good information thanks for sharing Best urology hospital in hyderabad
Post a Comment