PATIENT NAME: Renee WOODSAGE: 32SEX: FemaleDOB: June 17DATE…
PATIENT NAME: Renee WOODSAGE: 32SEX: FemaleDOB: June 17DATE OF CONSULTATION: January 8CONSULTING PHYSICIAN: Steve Foster, MD, UrologyREASON 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 shortness 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+.PLAN1. Treat with Ampicillin 400 mg q.i.d.2. Return to office if no improvement within 48 hours.