Identifying Data:
Name: MJ
Race: African American
Age: 54
Sex: female
Address: Queens, NY
Location: Jamaica
Source of Information: Self
Reliability: reliable
Chief Complaint:
abdominal/pelvic pain x 4 days
HPI:
Ms. MJ is a 54 y/o female with a pmhx of GERD here for suprapubic cramping pain. She has a burning sensation with urinating and her urine has a foul smell for four days now. She states the pain in her abdomen/pelvis is constant, non-radiating and rates it as 9/10. She has not tried anything to relieve the pain. She admits to urinary frequency, polyuria and fatigue. She denies fever, chills, nausea, vomiting, diarrhea or constipation, flank pain, incontinence, changes in vaginal discharge, hematuria or changes in urine color.
Past Medical History: GERD
Past Surgical History: none
Medications: none
Immunization: Patient has all childhood vaccines. COVID vaccine Johnson and Johnson May 2021
Family History:
Mother: hypertension, alive and well 83 years old
Father: hypercholesteremia, hypertension, alive and well 85 years old
Allergies: No known drug, food or environmental allergies
Social history:
Alcohol: socially only on Holidays
Smoking: never smoked
Illicit drug use: none
Travel: no recent travels
Occupation history: Elementary school teacher
Marital status: divorced
Sexual history: formerly heterosexual 1 partner, currently not sexually active for 3 years
Review of Systems:
General: denies night sweats, weakness, recent weight changes
Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.
Head: Denies headaches, vertigo or head trauma.
Eyes: Denies blurry vision, diplopia, fatigue with use of eyes, scotoma, halos, lacrimation, photophobia, pruritus.
Nose/sinuses: Denies discharge, epistaxis or obstruction.
Mouth/throat: Denies bleeding gums, sore tongue, mouth ulcers, voice changes or use of dentures.
Breast: Denies lumps, nipple discharge, or pain.
Pulmonary system: Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea.
Cardiovascular system: Denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, heart murmur.
Gastrointestinal: Denies hematochezia
Menstrual/obstetrical: LMP 4 years ago, denies vaginal bleeding. Never pregnant.
Nervous: Denies seizure, headaches, loss of consciousness, sensor disturbances, ataxia, loss of strength, changes in cognition/mental status/memory, or weakness.
Musculoskeletal system: Denies muscle/joint pain, deformity or swelling, redness or arthritis
Peripheral vascular system: Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.
Hematological system: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE
Endocrine system: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter
Psychiatric Denies depression/sadness, anxiety, OCD or ever seeing amental health professional.
Exam:
Vitals:
Right arm:
Seated 116/84
Respiration: 12 breaths /min unlabored
Pulse: 78 beats per minute, regular
Temperature: 97.4 degrees F (oral)
O2 Saturation: 98% on room air
Height: 65 inches
Weight: 148 lbs
BMI: 24.6 kg/m^2
General: Not in acute distress, A&O x 3.
HEENT: Normocephalic, atraumatic, non-tender to palpation throughout. Ears symmetrical without lesions, tympanic membranes intact with cone of light 5 o’clock AD and 7 o’clock AS, pearly white. Eyes symmetrical, EOMs intact OU, PERRL, sclera white, conjunctiva clear. Nose without deformities or discharge. Mouth has moist lips and mucous membranes, good dentition, tonsils and pharynx non-erythematous. Uvula rises midline with phonation.
Neck: Trachea midline, no carotid bruits noted. Carotid pulses 2+ bilaterally, no lymphadenopathy, thyroid non-tender, not enlarged, and no nodules noted.
Chest: chest rises symmetrically. No signs of accessory muscle use. Lat to AP diameter 2:1. Non-tender to palpation.
Lungs: Clear to auscultation. No adventitious breath sounds.
Heart: Regular rate and rhythm with S1 and S2 present. No murmurs, gallops or friction rubs.
Abdomen: Non-distended, normoactive bowel sounds present in all four quadrants, no bruits, non-tender to palpation, no rebound or guarding, no CVA tenderness.
Musculoskeletal: range of motion intact, strength 5/5 throughout.
Skin: No rashes, masses, lesions or discolorations noted.
Assessment/plan:
Ms. MJ is a 54 y/o female with a pmhx of GERD here for suprapubic pain. Dysuria, and foul-smelling urine. Likely urinary tract infection.
UTI
Order urinalysis with culture.
Nitrofurantoin 100 mg ER PO every 12 hours for 5 days.
