Woman – UTI, Vaginal discharge

new patient existing patient history provided by patient history provided by family member SO/family member present during visit chaperon/MA present during visit interpretation provided by family member/SO interpretation provided by MA

HPI/SYMPTOMS: new problem chronic condition acute exacerbation of chronic condition started today started yesterday started several days ago started more than 1 week ago started months ago started years ago unsure still present increasing in severity persisting occasional decreasing resolved affected by medication affected by exertion affected by pressure affected by position/movement affected by voiding worse at night as in cc

MEDICATIONS: allergies reviewed, taking OTC taking RX reports no side effects reports side effects effective partially effective not effective demonstrates knowledge of medications/reasons/dosages unable to name medications/reasons/dosages medication list/labels/containers available for review medication list/labels/containers not available for review none reported

PERTINENT MEDICAL HISTORY: stress travel new sexual partner PCP/UC/ER visit hospitalization/surgery/procedure new medications antibiotic use recent diagnostic study frequent UTIs frequent vaginosis kidney stones incontinence ovarian cyst endometriosis fibroids multiple pregnancies DM immunosuppression noncontributory none reported

Urinary: burning frequency pain with urination blood in urine back pain stress incontinence urge incontinence no sx reported

Vaginal: odor clear discharge yellow discharge brown discharge itching skin lesions painful intercourse postcoital bleeding vaginal bleeding vaginal clots vaginal tissue no sx reported

Menstrual: regular irregular heavy painful spotting missed postmenopausal

LMP:

Sexual: active inactive one partner multiple partners new partner oral vaginal anal

Last intercourse: yesterday several days ago one week ago weeks ago months ago protected unprotected

Birth Control: BCP Depo implant IUD BTL condoms none

GI: upper abd pain lower abd pain diarrhea constipation nausea/vomiting no sx reported

REVIEW OF SYSTEMS: negative except as stated in HPI
General:

HEENT:

CV:

Pulmonary:

MSK:

Neurologic:

Psychiatric:

Dermatologic:

Endocrine:

Hematologic/lymphatic:

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UA: non-specific changes normal suggestive of UTI leukocytes nitrites glucose blood declined urine cx sent out

hcg: N/A positive home test negative clinic test positive clinic test declined

OUTSIDE DIAGNOSTIC & LABORATORY RESULTS: normal non-specific changes no acute findings discussed with patient/SO no new results

General: well-appearing normal built heavy built lean well-nourished emaciated frail no signs of discomfort visible while sitting in chair no signs of discomfort visible while ambulating & getting on/off exam table ill-appearing tired-looking short of breath diaphoretic good hygiene disheveled bizarre clothes body odor drowsy appears impaired slumped no ambulation aids/DME ambulation requires walker ambulation requires cane ambulation requires wheelchair wearing cervical collar wearing lumbar support wearing extremity brace

Head/Face: normocephalic, atraumatic symmetrical face CN grossly intact plethoric face alopecia facial droop

Eyes: clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus visual acuity grossly intact cornea(s) clear glasses contacts conjunctival injection epiphora conjunctival exudate allergic shiners dysconjugate gaze

Ears: symmetrical & intact auricles bilaterally hearing to conversation intact clear canals without erythema or discharge TMs normal in appearance

Nose: nares patent bilaterally septum midline no facial tenderness mucosa pink & moist swollen & boggy mucosa mucosal congestion clear discharge yellow discharge crusty discharge rhinophyma

Mouth: tongue normal in appearance w/o lesions and with good symmetrical movements moist oral mucosa without lesions upper denture lower denture poor dentition oral ulcers gum swelling tooth decay

Throat: normal voice, no stridor patent pharynx w/o swelling or exudates uvula midline hoarseness vesicles on soft palate petechiae on soft palate pharyngeal erythema w/o exudates

Neck: symmetric with free painless ROM and no masses supple no LAD no bruit or JVD anterior LAD posterior LAD thyroid enlargement nuchal tenderness

Chest/Lungs: normal work of breathing, symmetrical chest expansion clear and equal breath sounds bilaterally chest wall atraumatic and non-tender no axillary or supraclavicular LAD SOB decreased bilaterally wheezing crackles

CV: regular rhythm no murmurs no ankle edema pedal skin warm with good & equal pulses tachycardia irregular heart rhythm systolic murmur calf tenderness ankle edema varicosities stasis discoloration

Abdomen: normal visual inspection, no distension normal active bowel sounds soft non-tender no bruit auscultated over AA and renal arteries protruding surgical scar umbilical hernia diffuse tenderness over entire abdomen w/o RRG hypoactive bowel sounds hyperactive bowel sounds direct non-rebound tenderness colostomy in situ deferred

MSK: no gross deformities, moves all extremities with good ROM for age full weight-bearing normal curvature & ROM in C- & L-spine for patient’s age non-tender C-spine with good ROM non-tender L-spine with good ROM strength, tone, & bulk symmetrical & grossly intact kyphosis paraspinal muscle spasm C-spine tenderness & DROM neck pain with active motion paracervical muscle spasm old surgical scar(s) in C-spine trapezius tenderness L-spine tenderness reduced painful ROM in lumbar region paraspinal muscle spasm trigger points in L-spine old surgical scar(s) in L-spine heel-walk & toe-walk without difficulty negative seated SLR positive seated SLR

Skin: grossly intact, no rashes no bruises normal turgor tattoos body piercings poor turgor dry sweaty

Neuro: normal concentration and attention memory grossly intact balance & coordination grossly intact ambulates w/o limp or alteration in gait extremities strong w/o atrophy no gross motor deficits sensation symmetrical & grossly intact no involuntary movements or tremor antalgic gait wide gait shuffling gait diffuse numbness w/o dermatomal pattern dystonia tardive dyskinesia tics

Speech/Vocalization: normal for age clear & coherent slurred mumbling to self monotonous stuttering hypoverbal hyperverbal loud soft slow rapid pressured groaning sighing crying perseveration flight of ideas repetitive questions self-depreciating statements repetitive statements of impending doom repetitive non-health related/financial concerns personal safety concerns suicidal ideation/threats insisting on particular medication, test, referral, or accommodation raising voice defensive argumentative cursing, swearing previous providers/staff criticisms verbal threats sexual remarks racist remarks

Behavior/Psychomotor Activity: calm, pleasant, respectful cooperative with history & exam guarded anxious irritable frustrated labile agitated hostile forceful pacing fidgeting picking skin twirling hair cracking knuckles grimacing, furrowing eyebrows tightening jaw breathing hard intense staring threatening gestures fist-clenching withdrawn flat affect bradykinetic indifferent appears to be responding to internal psychotic process

GU/Pelvic: no suprapubic tenderness no CVAT bilaterally s/p tenderness CVAT normal external genitalia no inguinal LAD declined

Discussion:

DX:
abdominal pain
cervicitis
dysfunctional uterine bleeding
herpes genitalis
incontinence of urine
menopause
ovarian cyst
pelvic pain
pid
pyelonephritis
ureterolithiasis
urinary tract infection
vaginal bleeding
vaginosis

.

PLAN OF CARE: patient/family verbalized understanding of dx and POC, agreed with dx and POC did not agree with dx and POC, encouraged to seek second opinion

ORDERS - MA: injection Rocephin 1 gm IM now none

ORDERS - RX: OTC ABX Pyridium 100 mg TID #6 Rx for suspected vaginosis Rx for suspected STI electronic paper given to MA to be transmitted to pharmacy none

ORDERS - LABS: CBC CMP TSH A1C UA urine cx vaginosis swab STI none

ORDERS - IMAGING: X-ray US MRI none

ORDERS - REFERRALS: local pharmacy to verify vaccination status and administer vaccines, if indicated deferred none

ORDERS - FORMS: excuse accomodations clearance return to school/work school/participation physical none

COORDINATION OF CARE

REVIEWED/DISCUSSED/INSTRUCTED ON: exam findings, POC, risks of/benefits of/alternatives to proposed POC, compliance with treatment regimen, appropriate follow up specific to condition, indications for immediate direct evaluation and/or contacting emergency services, previous visits laboratory/diagnostic studies specialty consults hospital visits medications PMP reporting medication side effects immediately medication compliance bringing all medications/labels to all visits home BP checks home BS checks daily weights controlling chronic conditions age- and disease-appropriate screening and immunization

DISCHARGE CONDITION/SAFETY: improved stable unchanged no safety concerns at this time safety concerns d/t depressed agitated mood safety concerns d/t impulsiveness safety concerns d/t hostile temper safety concerns d/t past attempts safety concerns d/t current suicidal verbalization

DISPOSITION: home advised to use UC for acute non-emergent problems advised of immediate need for further ER evaluation and treatment declined emergency transfer elected private transportation to ER left exam room before visit conclusion was asked to leave clinic

FOLLOW UP: as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, here in-person televisit 24 hours 1 2-3 5-7 10-14 30 60 90 days weeks months f/u acute episode f/u labs f/u imaging f/u new/changed rx f/u specialty consult

BARRIERS TO CARE: language barrier socio-cultural factors poor effort/cooperation with exam incomplete history history not supported by findings vague complaints supporting documentation unavailable failed to obtain old records failed to complete referrals or testing multiple comorbidities and/or polypharmacy multiple providers/prescribers multiple drug/treatment intolerance/failure frequent ER/UC visits frequent office contacts poor compliance with POC negative attitude to proposed tx lack of interest in non-drug tx overreliance on short-acting meds overwhelming focus on Rx drugs poor insight lack of motivation dependent attitude preoccupation with illness unhealthy coping mechanisms somatization catastrophization pessimism overgeneralization unrealistic health beliefs psych comorbidity anxiety depression alcohol or substance use social or occupational dysfunction secondary gain hostile/disruptive behavior affect none noted at this time

Woman – UTI, Vaginal discharge

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