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dysuria1 of 9 draggables.
UTIs2 of 9 draggables.
pain3 of 9 draggables.
leukorrhea4 of 9 draggables.
shortness5 of 9 draggables.
foul6 of 9 draggables.
nausea7 of 9 draggables.
Urinalysis8 of 9 draggables.
urine9 of 9 draggables.
URINARY SYSTEM – CONSULTATION REPORT

PATIENT NAME: Renee WOODS
AGE: 32
SEX: Female
DOB: June 17
DATE OF CONSULTATION: January 8
CONSULTING PHYSICIAN: Steve Foster, MD, Urology

REASON FOR CONSULTATION: Urinary Tract Infection.

HISTORY: The patient is a 32-year-old female who is complaining of pain on urinating. Patient states it began approximately 3 days ago. The patient describes symptoms of
and increased frequency to the washroom. Patient states they usually go to the washroom to urinate 4-5 times a day, but starting 3 days ago, she started going 10-12 times per day. Sometimes no
comes out. The urine has a
odor and is cloudy. States there has been lower abdomen
since yesterday, and says it is worse when she tries to go with no result. Patient has had the same sexual partner for 10 years. She has a history of
and feels this is the same.

PHYSICAL EXAMINATION: GENERAL: No weakness, or tiredness. VITALS: Blood pressure 120/80, heart rate 70 and respirations 16. Patient weighs 150 pounds. LUNGS: No cough or
of breath. GASTRO: Denies
, vomiting or change in bowel habits.
URINARY/REPRODUCTIVE: Denies hematuria, or any
.

ASSESSMENT: Did a urinalysis on patient.
revealed leukocytes 3+.

PLAN
1. Treat with Ampicillin 400 mg q.i.d.
2. Return to office if no improvement within 48 hours.


______________________________
Steve Foster, MD, Urology