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“I have painful and frequent urination.”
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History of Present Illness
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VZ is a 19-year-old Hispanic female who presents to the urgent care walk-in clinic with dysuria and polyuria for 3 days duration.
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Mother has HTN; father has HTN, type 2 diabetes mellitus, and dyslipidemia
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Currently attending college as a sophomore. Smokes tobacco and marijuana cigarettes socially on weekends for the past 2 years; drinks alcohol (beer and wine) socially on weekends for the past year. Sexually active with her boyfriend of 8 months; uses condoms
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Ethinyl estradiol/etonogestrel 0.015 mg/0.12 mg unwrap and insert one ring intravaginally and remove every 21 days then repeat 7 days later
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Cetirizine 10 mg PO daily PRN seasonal allergies
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Triamcinolone acetonide 55 mcg/spray 1–2 sprays EN PRN seasonal allergies
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Phenazopyridine hydrochloride 200 mg PO TID after meals
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Temp 98.4°F, P 62, RR 10 breaths per minute, BP 112/82 mm Hg, pO2 98%, Ht 5′6″, Wt 52.3 kg
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Thin, well-nourished female, lying in bed, NAD, AAO × 3
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EOMI, PERRLA, normocephalic, no pharyngeal exudate. Neck, supple. Thyroid palpable, no nodules. No lymphadenopathy
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CTAB without wheezing or crackles
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Soft, non-distended, non-tender, positive bowel sounds hyperactive, no rebound or guarding
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Normal female genitalia, complaints of dysuria, denies hematuria. No malodorous discharge noted from vagina
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PERRLA, no focal deficits noted
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Edema present in lower extremity bilaterally. Pedal pulses palpable
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No tenderness to palpation on lower lumbar region
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Dipstick Urinalysis:
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Macroscopic: urine midstream, clean catch. Yellow, cloudy, large leukocytes, positive nitrites, urine pH = 8, urine hemoglobin, protein, glucose, ketones, and bilirubin negative, specific gravity = 1.012
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Microscopic: WBCs >100, RBCs 0, squamous epithelial cells 0, few WBC clumps
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