History of present illness: 35-year-old female patient presents to clinic today for “pain with urination” that
started three days ago. Patient denies frequency but does feel the urgent need to urinate and “some slight
burning.” She denies any foul odor. Denies fever, chills, N/V/D.
Chief Complaint: “pain with urination”
History of present illness: 35-year-old female patient presents to clinic today for “pain with
urination” that started three days ago. Patient denies frequency but does feel the urgent need
to urinate and “some slight burning.” She denies any foul odor. Denies fever, chills, N/V/D.
Patient stated that she has attempted to increase her fluid intake and used OTC Azo for pain
management.
Past Medical History: Kidney stones (2008), Appendicitis (2012)
Surgical History: Lithotripsy with stone removal & ureteral stent placement (2008),
Appendectomy (2012), Right clavicle fracture (2019)
Family History:
Mother: Age 60, Hypertension, depression
Father: Age 62, Diabetes Type 2, obesity, CAD, MI, cardiac stents x2.
Siblings:
o Brother (Andrew, 31): No medical history or surgeries.
Maternal Grandmother: Age, 79, Hypertension
Maternal Grandfather: Deceased at age 79, Stroke, hypertension.
Paternal Grandmother: Age 81, Breast cancer, osteoporosis
Paternal Grandfather: Deceased at age 77, CAD, MI, diabetes type 2, hypertension
Social History:
Married, 1 child (son, age 9), sexually active with spouse only. Heterosexual.
Employment: 4th grade teacher, currently enrolled in master’s degree program Health
Exams:
o Medical exam-reported last physical was in March, states “I get them around my
birthday every year.”
o Dental exam-reports an upcoming cleaning appointment. Last dental exam was
completed around 6 months ago.
o Vision exam-recently got annual exam eye due to needing replacement contacts.
States “I go every year so that I can make sure I have the correct prescription for
my contacts and glasses.”
started three days ago. Patient denies frequency but does feel the urgent need to urinate and “some slight
burning.” She denies any foul odor. Denies fever, chills, N/V/D.
Chief Complaint: “pain with urination”
History of present illness: 35-year-old female patient presents to clinic today for “pain with
urination” that started three days ago. Patient denies frequency but does feel the urgent need
to urinate and “some slight burning.” She denies any foul odor. Denies fever, chills, N/V/D.
Patient stated that she has attempted to increase her fluid intake and used OTC Azo for pain
management.
Past Medical History: Kidney stones (2008), Appendicitis (2012)
Surgical History: Lithotripsy with stone removal & ureteral stent placement (2008),
Appendectomy (2012), Right clavicle fracture (2019)
Family History:
Mother: Age 60, Hypertension, depression
Father: Age 62, Diabetes Type 2, obesity, CAD, MI, cardiac stents x2.
Siblings:
o Brother (Andrew, 31): No medical history or surgeries.
Maternal Grandmother: Age, 79, Hypertension
Maternal Grandfather: Deceased at age 79, Stroke, hypertension.
Paternal Grandmother: Age 81, Breast cancer, osteoporosis
Paternal Grandfather: Deceased at age 77, CAD, MI, diabetes type 2, hypertension
Social History:
Married, 1 child (son, age 9), sexually active with spouse only. Heterosexual.
Employment: 4th grade teacher, currently enrolled in master’s degree program Health
Exams:
o Medical exam-reported last physical was in March, states “I get them around my
birthday every year.”
o Dental exam-reports an upcoming cleaning appointment. Last dental exam was
completed around 6 months ago.
o Vision exam-recently got annual exam eye due to needing replacement contacts.
States “I go every year so that I can make sure I have the correct prescription for
my contacts and glasses.”
