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Patient Demographics
Identification (ID)- Patient Initials: A.E.
Date of Birth: 03/13/
Age: 20 years old
Sex/Gender: Identifies as Female
Contact Information: Phone + Email
Race/Ethnicity: White
Date of Visit: 7/19/21 @ 3:00 p.m.
Pronouns: She, her, hers
Advanced Directives/Power of Attorney: 1st
alternative HC agent is mother
Insurance: private insurance/ Medica
Primary Care Provider: Provider per regular PC
clinic in hometown
Source & Reliability of Info.: Patient-Reliable
Historian
Referral No referral for this apt.
Subjective:
Chief Complaint:
“I think I have a UTI, because I am peeing all the time, have terrible pain & burning when I pee, and can
see blood in my pee right at the end too”
History of Present Illness (HPI): Patient as own historian
Patient reports that her urinary symptoms first began two days ago, but most significantly early this morning and today. Reports pain with urination, sudden urge to urinate, blood in the urine. Past medical history remarkable for sexually transmitted infection (STI) Chlamydia about a month ago that was treated and partner also was treated. Waited 7 days for intercourse post-treatment. No history of kidney stones, interstitial cystitis, overactive bladder, vaginitis, STI or PID. Pertinent Negatives: Denies urinating more than usual, awakening during the night to urinate, abdominal heaviness or pain, cloudy appearance, or foul smell to urine. Patient reports no loss of bladder control, vaginal discharge or drainage, genital sores or skin concerns, genital or vaginal itching, fever/chills, nausea/vomiting, back pain. Has never had a UTI diagnosis before. Pertinent Positives: Has been sexually active. Has been tested for STIs in the past. Has not had any new sexual partners since that time. Requests STI screen today. Last menstrual period: July 05, 2021. Reports swimming in lake all weekend in one- piece bikini & probably actually using a bathroom much less than on a usual day or weekend. Reports having sexual intercourse the previous night and noticing that voiding after felt weird but still nothing like it feels to urinate today. Did have both oral and vaginal sex with male partner that had been previously exposed to chlamydia w/ unknown follow-up & or treatment after.
Allergie
s
Name Reaction Treatment
Amoxicillin Uticaria/Hives/Anaphylaxis Epi Pen/Hx. Of needing PO steroids Apples Uticaria/Hives/Anaphylaxis Epi pen/Hx of throat constriction w/o need for PO steroids or inpatient care
Past Medical History
Disease/Condition Onset Resolved/Treated Managed w/ current tx.
Unremarkable
Infectious Diseases:
-Pervious testing, diagnosis, and treatment completion for chlamydia 1 month ago
Surgeries/Hospitalization: - previous tonsillectomy at a young, pre-kindergarten age and wisdom tooth
extraction in late adolescents but unable to obtain specifics regarding procedures. Anesthesia tolerated WDL & no complications.
Current Medications:
Medication Dose^ Instructio
n Taking as Prescribed & Last Dose Controlling Condition/Problem? PO Birth Control (per PCP, pt. doesn’t know name/specifics) unknown unknown Pt. reports she is taking as prescribed Yes
Immunizations Status: All childhood & recommended immunizations + TDAP up to date.
Family History: Negative for any pertinent or relevant conditions
Personal/Social History:
General: Wear seatbelts 100% of the time & has a driver’s license, Home Environment: single & living with roommate in all-girls dorms, Patient feels safe at home and in current living environment on campus. Student at NDSU-elementary education. Current health habits and/or risk factors/stress management/hobbies: swimming, lake activities, camping, Pt. feels safe in their home, minimal alcohol use reported. Denies tobacco, nicotine, vape, & drug use or abuse.
Pertinent Diagnostics/Data:
Type of Diagnostic test/image Date Results Significance
To be obtained
Objective
VS:
Height: 66” Weight: 152 lb. BMI: 24.6 BP: 115/70 HR: 86 Temp: 98.9F
RR: 14 SPO2: 99%
Pain: 0/10 at rest, burning w/ urination and pain level unsure but enough pain that when patient voids she “cannot
sit still and cannot help but squirm and fidget around it’s so bad” until done voiding
Physical Examination:
General : A. E. is a 20-year-old, Caucasian female that appears her recorded age and in no obvious physical
distress. Patient is alert and responds appropriately, both verbally & nonverbally, to questions, requests, and commands. Speech is even and controlled, gate is symmetrical and coordinated, & patient is relaxed but not exactly comfortable-looking, but seems well hydrated & well nourished.
Integument: Exposed & inspected skin is warm, dry, pink intact, with good turgor or without tenting. No
excoriations or lesions. Female distribution, fine, full, & silky brown with even distribution. Nail beds pink and firm, instant capillary refill, no inflammation or clubbing.
Head & Face: Normocephalic w/o edema nor any abnormal lesions or muscle movements. Facial expression
relaxed, symmetric, w/o any weakness.
Mouth/Throat/Neck: Lips atraumatic. Buccal mucosa pink, moist, intact. Dentation excellent w/ no decay or
abnormalities. Gingiva pink, firm, w/ tight teeth margins. Tongue pink, moist, intact, & atraumatic w/ no abnormal
Vaginitis r/t candida infection/ other -Dysuria -No external burning or pain -No vaginal discharge, skin changes, itching ( Hematuria post labs )
Same as above: if all –
results for above vaginitis swab & STI testing indicated Pyelonephritis -frequency & dysuria -No CVA/flank pain or tenderness or back pain -No abdominal pain/tenderness -No systemic s/s: fever, N/V -S/S less than 1 day w/ no risk factors present Same as UTI + importance that C & S completed always Interstitial Cystitis -in population impacted most often by this condition -urgency -no bladder pain or nocturia -pain occurs with voiding and IS NOT relieved by voiding -No abdominal/vaginal pain Same as above/for UTI
Plan of Care
Further Investigation & Diagnostics ordered:
Labs- Urinalysis Completed (N30.01) Urine Color (Yellow) Urine Clarity (Slightly Cloudy) Urine Glucose (Negative mg/dL) Urine Bilirubin (Negative ) Urine Ketones (Negative mg/dL) Urine Specific Gravity (1.020 ) Urine Blood (Large ) Urine pH (7.0 ) Urine Protein (30 mg/dL mg/dL) Urine Urobilinogen (0.2 E.U./dL EU/dL) Urine Nitrite (Negative) Urine Leukocytes (Moderate ) Urine White Blood Cells (6-10 #/HPF) Urine Red Blood Cells (4-10 #/HPF) Urine Squamous Epithelial Cells (Many (>30/hpf) Urine Bacteria (Moderate (50-100/hpf)
Impression:
- Uncomplicated UTI with hematuria (N30.01)
- Encounter for STI screenings (Z11.3) I discussed with patient my clinical impression and urinalysis and overall findings. Urinalysis, history, physical exam, and reported complaints/symptoms are consistent with an uncomplicated UTI.
Interventions & Treatments:
Nitrofurantoin (Macrobid) 100 mg capsule PO 2X per day for 5 days e-scribed to student health
pharmacy per patient request to treat her uncomplicated UTU (N30.01).
OTC Pyridium and ibuprofen/Tylenol recommended to alleviate pain, discomfort, and related urinary
symptoms. Education on how to take each medication discussed given as well as information about each
medication in general and expectations. Patient also educated that urine/body fluids may turn a bright
yellow from Pyridium if taken and that that was completely normal and expected.
Addressment of need for follow-up STI screening and testing discussed after recent exposure the previous evening. I recommend deferring STI testing for two more months given her recent chlamydia infection and treatment about one month ago. Patient and I discussed that there is a high likelihood of false positive results after initial treatment, why, and her available options and preferences.
Patient Education, Counseling, & Professional Recommendations: Verbal education and information handout given to patient about diagnoses, treatment, symptom management, and prevention of future infections. Patient instructed to begin antibiotic therapy as prescribed and to finish the entire course of therapy even if her symptoms resolve prior to final dose. Informed that she should expect to see an improvement in her symptoms likely within the day but could take longer. However, symptoms should not persist more than 48 hour of starting antibiotics and if this occurred patient instructed to contact the clinic via any means and/or come back in for additional testing. Also discussed symptoms of pyelonephritis and instruction to follow-up should flank pain, fever, chills, or general feeling of unwell should continue despite starting antibiotics. She is denying any vaginal concerns or s/s or manifestations today. Patient denied any questions or concerns at the close of the visit. Encouraged to follow-up with any questions or concerns. Health Promotion UTI Prevention Education- ● Patient encouraged to increased fluid intake and drink at minimum 64 ounces of fluid per day. ● Discussed UTI prevention interventions and major contributors to avoid or manage. ● Instructed patient to- o Void after intercourse o Wipe front to back after using the bathroom o Maintain hydration as much as possible o Take extra care and/or shower/bath or perform perineal hygiene prior to intercourse AND after, after: ▪ Being in/at the lake all day prior to intercourse ▪ Going swimming or after prolonged time in any body of water ▪ A full day of performing vigorous physical activities or activities causing diaphoresis most of the day ▪ Any other activities that increase her exposure to bacteria/organisms and/or promote and increase bacterial growth Follow-Up Plan & Future Monitoring: Follow-up plan for 2 months from now with a patient choice of whether she would like a regular provider visit or simple nursing visit. 2-month follow-up scheduled for STI re-screening and complete STI testing per exposure and recommendations. Patient in full agreement with treatment and follow-up plan and does want to be re-tested in 2 months to ensure negative STI status continue. Billing Codes: 99213 - OFFICE/OP VISIT MEDICALLY APPROPRIATE HX/EXAM; LOW LEVEL MED DECISION; 30- MIN 81001 - URINALYSIS, DIP STICK/TABLET REAGENT; AUTOMATED W/MICROSCOPY 4450F - SELF-CARE EDUCATION PROVIDED TO PATIENT UPTODATE PATHWAY Urinary tract infection (UTI): Empiric antibiotic selection for acute complicated UTI in adults; Version 8. Date Consulted: Sun Dec 05 2021 18:35:31 GMT-0600 (Central Standard Time) Summary: Critical illness or urinary tract obstruction: No. Inpatient management anticipated: No. Risk factors for MDR infection: No.
