Exam (elaborations)
I Human J Mirabelle 25year/old female, reason:: pain with urination
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I Human J Mirabelle 25year/old female, reason:: pain with urination
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I Human J Mirabelle 25year/old female, reason:: pain with urination :HPI year old female p/w 3 day history of dysuria, urinary frequency as well as mucopurulent vaginal 25 discharge. She denies fever, chills, myalgia. She has a previous hx of UTI, smoking, and multiple sex .partners with some unprotected sex.The pain is alleviated by a warm bath and increased with standingPhysical exam shows cervical friability :Questions
?How can I help you today .1
?Do you have any other symptoms or concerns we should discuss .2
?When did your pain/discomfort with urination start .3
?Do you have fever?/Have you been having fevers .4
?What is the appearance, smell, texture, and quantity of the vaginal discharge .5
?Does anything make your pain/discomfort with urination better or worse .6
?How severe is your pain/discomfort with urination .7
?Do you have vaginal discomfort or itching .8
?Have you had vaginal discharge/discomfort like this before .9
?Are you sexually active .10
?Do you have more than one sexual partner .11
?Have you had any sexually transmitted infections .12
?Do you have allergies .13
?Are your immunizations up to date .14
?When did your last period begin .15
?Are you having or have you had unprotected sex .16
?Is your pain/discomfort worse with start or end of urination .17
?Do you have pain with sex .18
?Has there been a change in your urination frequency .19
?Do you use precautions to prevent the transmission of sexual infections .20
?Do you have bleeding between your menstrual cycles .21 ?Are you taking any OTC or herbal medications .22
?Any new or recent changes to your medications .23
?Do you have new or multiple sexual partners with similar symptoms .24 Do you have problems with heat or cold intolerance, increased thirst, increased sweating, frequent .25
?urination, or change in appetite
?(Is your urine pink or red in color (blood in urine .26 ,Do you have any problems with fatigue, difficulty sleeping, unintentional weight loss or gain, fevers .27 ?or night sweats
?Do you have any problems with an itchy scalp, skin changes, moles, thinning hair, or brittle nails .28 Do you experience chest pain discomfort or pressure; pain/pressure/dizziness with exertion or .29
?getting angry; palpitations; decreased exercise tolerance; blue/cold fingers and toes Do you experience shortness of breath, wheezing, difficulty catching your breath, chronic cough, or .30
?sputum production ,Do you have problems with nausea, vomiting, constipation, diarrhea, coffee grounds in your vomit .31
?dark tarry stools, bright red blood in your bowel movements, early satiety or bloating ,Do you have problems with muscle or joint pain, redness, swelling, muscle cramps, joint stiffness .32
?joint swelling, or redness, back pain, neck or shoulder pain, or hip pain
?Do you have genital sores or discharge .33
?Do you feel when you need to urinate that you need to urgently .34
Have you had problems with pain/discomfort with urination like this before .35 :Physical Exam
-Vitals:
oTemp: 98.6 F
oPulse: 64 regular o BP: 118/62
oRespiration: 12 o PE
-GU: No labial ulcerations or lesions, Vaginal walls pink without excoriations, Bimanual exam without cervical motion tenderness.
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