Genitourinary Assessment
CC: Increased frequency and pain with urination
HPI:
T.S. is a 32-year-old woman who reports that for the past two days, she has dysuria, frequency, and urgency. Has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months.
Medical History:
None
Surgical History:
- Tonsillectomy in 2001
- Appendectomy in 2020
Review of Systems:
- General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
- Abdominal: Denies nausea and vomiting. No appetite
Objective
VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.
Pelvic Exam:
- mild tenderness to palpation in the suprapubic area
- bimanual pelvic examination reveals a normal-sized uterus and adnexa
- no adnexal tenderness.
- No vaginal discharge is noted.
- The cervix appears normal.
- Diagnostics: Urinalysis, STI testing, Pap smear
Assessment:
- UTI
- STI
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