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Chief Complaint

“I have painful and frequent urination.”

History of Present Illness

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.

Past Medical History

Seasonal allergies

Surgical History


Family History

Mother has HTN; father has HTN, type 2 diabetes mellitus, and dyslipidemia

Social History

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


Sulfas-rash and blisters

Home Medications

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

Cetirizine 10 mg PO daily PRN seasonal allergies

Triamcinolone acetonide 55 mcg/spray 1–2 sprays EN PRN seasonal allergies

Phenazopyridine hydrochloride 200 mg PO TID after meals

Physical Examination

Vital Signs

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


Thin, well-nourished female, lying in bed, NAD, AAO × 3


EOMI, PERRLA, normocephalic, no pharyngeal exudate. Neck, supple. Thyroid palpable, no nodules. No lymphadenopathy


CTAB without wheezing or crackles


NSR, no m/r/g


Soft, non-distended, non-tender, positive bowel sounds hyperactive, no rebound or guarding


Normal female genitalia, complaints of dysuria, denies hematuria. No malodorous discharge noted from vagina


PERRLA, no focal deficits noted


Edema present in lower extremity bilaterally. Pedal pulses palpable


No tenderness to palpation on lower lumbar region

Laboratory Findings

Dipstick Urinalysis:

  • 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

  • Microscopic: WBCs >100, RBCs 0, squamous epithelial cells 0, few WBC clumps

Urine Gram Stain

Many gram-negative rods



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