Health Care > EXAM > Chief Complaint: “pain with urination” (All)
History of present illness: 35-year-old female patient presents to clinic today for “pain with urination” that started three days ago. Patient denies frequency but does feel the urgent need to u... rinate and “some slight burning.” She denies any foul odor. Denies fever, chills, N/V/D. Patient stated that she has attempted to increase her fluid intake and used OTC Azo for pain management. Past Medical History: Kidney stones (2008), Appendicitis (2012) Surgical History: Lithotripsy with stone removal & ureteral stent placement (2008), Appendectomy (2012), Right clavicle fracture (2019) Family History: Mother: Age 60, Hypertension, depression Father: Age 62, Diabetes Type 2, obesity, CAD, MI, cardiac stents x2. Siblings: o Brother (Andrew, 31): No medical history or surgeries. Maternal Grandmother: Age, 79, Hypertension Maternal Grandfather: Deceased at age 79, Stroke, hypertension. Paternal Grandmother: Age 81, Breast cancer, osteoporosis Paternal Grandfather: Deceased at age 77, CAD, MI, diabetes type 2, hypertension Social History: Married, 1 child (son, age 9), sexually active with spouse only. Heterosexual. Employment: 4th grade teacher, currently enrolled in master’s degree program Health Exams: o Medical exam-reported last physical was in March, states “I get them around my birthday every year.” o Dental exam-reports an upcoming cleaning appointment. Last dental exam was completed around 6 months ago. o Vision exam-recently got annual exam eye due to needing replacement contacts. States “I go every year so that I can make sure I have the correct prescription for my contacts and glasses.” Religion: Christian, active in church every week on Sunday Caffeine Use: 1 coffee in the morning, sometimes a soda at lunch (soda-3 a week) [Show More]
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