REASON FOR VISIT: Pelvic pain and dysuria.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who comes in complaining of pelvic pain and dysuria. She had called the office three weeks ago and we had spoken with her, at which time she complained of dysuria and increased frequency. As we were unable to get her into the office that morning, we had given her prescriptions for Bactrim and Pyridium. The patient reports that she took both of these. She found the Pyridium helpful, but when she discontinued it, she had really no improvement in her symptoms. The patient subsequently called and spoke with Dr. John Doe and had an order faxed to her place of work where she had a urine culture done, which showed growth of E. coli with a wide range susceptibility and was given Cipro 250 mg for a 7-day course with a couple of tablets still remaining.
The patient again has not noted any improvement while on this dose of medication. She also notes some discomfort in her pelvic area with voiding but denies any discharge. She is active and reports that her partner lives overseas. The patient last saw him and was sexually active in mid March and notes that her symptoms began shortly after that time. The patient also reports that over this time frame, she has been feeling generally fatigued and run down, but denies any change in her appetite or bowel habits and has not had any fevers. The patient does typically follow with her gynecologist. The patient states that she had her routine pelvic done last fall. Of note, the patient has been on a regimen of hormone replacement therapy for approximately one year.
CURRENT MEDICATIONS: Hormone replacement therapy.
ALLERGIES: None known.
PHYSICAL EXAMINATION: Blood pressure 122/80 mmHg, temperature 98.6 degrees, pulse 68 beats per minute, and oxygen saturation 98% on room air. General: The patient is alert, oriented, pleasant, and friendly. The patient is in no acute physical distress and does not seem anxious or depressed. Lung sounds are clear. Heart has regular rate and rhythm. Abdomen is soft with vague suprapubic area tenderness. No masses palpated. Bowel sounds are normoactive. No rebound or guarding. No CVA tenderness. External genitalia are normal without lesion. No inguinal lymphadenopathy. Vagina is pink with rugae. Cervix is midline. There is a scant white discharge. Cultures for BV, yeast, gonorrhea, and Chlamydia obtained. Bimanual is significant for vague tenderness throughout. No focal cervical motion tenderness, adnexal tenderness, or masses noted.
DIAGNOSTICS: A urine dip is negative for blood, nitrites, or leukocytes but will be sent for culture.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old female patient with dysuria and pelvic pain times approximately one month. It is noted that the patient had a urine culture positive for E. coli, but showing sensitivities to both antibiotics that she has taken. Also noted that symptoms began after recent intercourse with her partner. The plan will be to send off culture, check labs including a CBC, CMP, as well as other routine studies, which she is overdue for including a TSH given that she mentions fatigue. Over the weekend, the patient will finish up the Cipro that is remaining, and we also gave her two days worth of Pyridium for symptomatic relief. We will communicate regarding the results of her studies on Tuesday, and if a source for her current symptoms cannot be identified, we have discussed either setting her up for a pelvic and bladder ultrasound or referring her back to her gynecologist. We will communicate, therefore, on Tuesday. The patient is agreeable and comfortable with this plan.
