SOLVED325

Chart 1 Patient: Jane Doe DOB: 8/11/19XX Chief Compliant: UTI History of Present Illness (HPI): Jane complains of painful urination for the past 2 to 3 days accompanied by urinary frequency, as well. She had some spotting noticed while wiping. No fever. No N, V, D, cough or nasal sx. Appetite normal. Takes Culturelle daily, which keeps her bowels regular and prevents constipation. Patient has been seen several times over the past year for complaints of dysuria with negative culture results. No known allergies, No regular medications, No changes to PFS HX Exam: Vitals: W: 99 lbs, Temp: 98.2F CONST: Cooperative, healthy appearing, no acute distress, well developed, alert HENMT: Head: normal to inspection, Mouth: oral mucosae normal, oropharynx normal, moist mucous membranes, no trismus, Teeth and Gingiva: dentition normal, gingiva normal EYES: General: appearance normal, both eyes and all related structures, Conjunctivae: conjunctivae normal NECK: Thyroid: normal, Lymphatic: no lymphadenopathy noted CARDIO: Rate: regular rate, Rhythm: regular rhythm, Heart Sounds: S1 normal, S2 normal, no murmurs, no clicks, no rubs GI: Inspection: normal to inspection, non-distended, Palpation: soft, no hepatosplenomegaly, no guarding, no hernias, Auscultation: normal bowel sounds GU: External female exam, normal appearance, no discharge, mild vulvar
SCIENCE
HEALTH SCIENCE
NURSING

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