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WEEK 7 CASE STUDY AT A GLANCEJames BostickNSG 64301/14/2021
SYNOPSIS •The patient Judy Pham, (18-year oldfemale) presents to the clinic after her initial 3 month visit prior with acute onset dysuria and urinary frequency x 2 days. The patient denied symptoms of fever, N/V, back pain, and/or vaginal discharge. The patient stated that prior to coming into the clinic this morning, she had been experiencing some hematuria and suprapubic pain. The patient did admit that since her last visit, she has been dating someone for the past 2 months and they have recently engaged in unprotected sexual intercourse.
HPI•The patient came into the clinic with complaints of dysuria and urinary frequency x 2 days. The patient denied fever, N/V, back pain and/or vaginal discharge. However, the patient did admit to experiencing hematuria and suprapubic pain this morning prior to her clinic visit. The patient does admit to having a new partner in which she has been engaging in recent unprotected sexual intercourse.
MEDICAL HISTORYNKDAPatient denies any past medical history.
FAMILY HISTORYMother: No history, alive.Father: No history, alive.Sister (younger): No history, alive.
SOCIAL HISTORY•Occupation: Current college student•Denies tobacco use and/or illicit drug use.•Admits to drinking beer once every few months.
EXAMINATION•General:Ms. Pham is a pleasant 18-year old female patient. Patient answers questions appropriately and presents as well groomed.•Cardiovascular:S1/S2 with regular rate and rhythm, no MGR. Radial/peripheral bilaterally 2+. No edema noted.•Respiratory:Lungs CTA, with no wheezing noted.•Integumentary: Warm and dry. No wounds and/r lacerations noted.•Musculoskeletal:Full ROM in all extremities. No lower back pain, tenderness, and/or deformities noted.•Gastrointestinal:x 4 active bowel sounds. Mild midline suprapubic tenderness noted. No bladder distension noted.•Breast: Free of masses, tenderness, and/or discharge.•Genitourinary: Upon examination of genitalia via pelvic exam, no ulcerations, redness, and/or other abnormalities of the skin. Small to moderate amount of white of vaginal mucus noted. Otherwise, cervix normal in appearance.