GI and GU Evaluation

C.C. Burning with urination, fever, N/V
HPI: 16 y.o. F presented to Clinic with grandfather for burning with urination that she began three days
ago. She noticed that she was going to the bathroom more than normal. She recalls normal urinary
frequency as four times daily, but for the past three days she has felt the urge to go to the bathroom six
to eight times daily and has not been able to produce urine every time. She has also experienced
increased burning during urination when she is able to produce urine. Yesterday she started to have
lower abdominal pain, which worried her so her mother called the office to make an appointment for
today but only her grandfather could bring her. She states that the pain is worse when she has the urge
to go the bathroom and cannot produce any urine. The pain decreases a little between the urgency
episodes. The patient rates the pain as a 6/10 today. She says that it has gotten worse every day over
the past three days. She tried Tylenol with some relief. She also reports fever chills, today developed
nausea with one episode of vomiting. The patient believes that she has a urinary tract infection because
she remembers having one a few years ago that presented with the same symptoms.
Allergies: Penicillin (rash)
Current Mediation: MVI 1 tab PO daily.
Childhood Illnesses. Chicken Pox. Asthma. Urinary Tract Infection age 15. Immunizations: Patient does
not receive regular flu vaccines. Screening tests: Patient does not go to the eye doctors and states that
she does not have any trouble with her vision.
Family History: Mother – Lung cancer, heart disease, hypertension, diabetes. Father – Diabetes.
Maternal grandfather deceased at 61 due to heart attack and maternal grandmother has diabetes and
HTN. Paternal grandfather has a PMH seizures and paternal grandmother deceased at age 51 due to
breast cancer
Social History: Patient denies drug, ETOH or illicit drug use. She is a high school senior who plans to go
into the military after graduation. She is unemployed. She is not sexually active.
Exercise & Diet: Patient does have a regular exercise routine. Patient states that she cooks a lot of
prepared frozen food for her or she just eats out.
Safety Measures: Wears seat belt.
HEENT: Denies headaches, sinus problems, epistaxis, hoarseness, dental problems, oral lesions, hearing
loss or changes, nasal congestion. Denies blurred vision, difficulty focusing, ocular pain, diplopia,
scotoma, peripheral visual changes, and dry eyes. Patient states she does not wear glasses or contacts.
Patient has never seen an eye doctor
Neck: No neck pain or stiffness. She denies any limitation of motion or any lumps. She states she has
noticed some swelling to her glands.
CV: Patient states she exercises 2 to 3 times a week. She denies any history of a heart murmur, chest
pain, palpitations, dyspnea, activity intolerance, varicose veins, or edema.
Lungs: Patient denies cough, SOB on exertion, difficulty breathing, wheezing, pain on inspiration, history
of respiratory infections, exposure to TB, hemoptysis. Patient states she has not had a chest x-rays in the
past. Her last TB skin test was done in September 2019 for volunteer work and it was negative.
GI: Denies, nausea, vomiting, dysphagia, reflux, pyrosis, loss of appetite, bloating, diarrhea, constipation,
hematemesis, epigastric pain, hematochezia, food intolerance, flatulence, hemorrhoids or change in
bowel habits.
GU: She denies heavy bleeding or incontinence. She had her first period at the age of 12. She is not
currently sexually active. States she has dysuria with urinary urgency and frequency x 3 days.
PV: She denies deep leg pain, cold hands/feet, varicose veins, thrombophlebitis, or leg cramps. Patient
denies bruising or bleeds easily or history of any blood transfusions.
MSK: Patient denies joint pain, swelling, muscle pain or cramps, neck pain or stiffness, or changes in
ROM.
Neuro: Patient denies transient weakness, numbness, muscular weakness, tingling, memory difficulties,
involuntary movements or tremors, syncope, stroke, seizures, or paresthesia.
Endo: Patient denies thyroid problems, cold or heat intolerance, polydipsia, polyphagia, polyuria,
changes in skin, hair or nail texture, unexplained change in weight, changes in facial or body hair,
changes in hat or glove size, or use of hormonal therapy.
Psych: Patient denies nightmares, mood changes, anxiety, depression, nervousness, insomnia, suicidal
thoughts, and exposure to violence, or excessive anger.
Objective:
Physical Examination (PE):
VS: BP: 102/60, HR: 76, RR: 18, Temp 98.5, weight: 129, height: 63inches, BMI: 22.7.
Gen: Patient well-nourished and appears stated age. No acute distress noted. Ambulating without
assistance.
Skin: No lesions present.
HEENT: Normocephalic. Eyes Sclera white. Conjunctivae pink. Pupils are PERRL, 3 mm bilaterally.
Extraocular movements intact. Hearing is intact. Nose normal with no mucous, inflammation or lesions
present. Nares patent. Septum is midline. Pink, moist mucous membranes. No missing or decayed teeth.
Throat: no inflammation or lesions present.
Neck: Had a supple and with no pain, patient was negative for lymphadenopathy
CV: S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubs. Carotid Arteries: normal pulses
bilaterally, no bruits present. Pedal Pulses: 2+ bilaterally. Extremities: no cyanosis, clubbing, or edema,
less than 2 second refill noted
Lungs: Even and unlabored. Clear to auscultation bilaterally without wheezes, rales, or rhonchi.
Abd: soft, flat, nontender without masses or hepatosplenomegaly. Bowel sounds active. No bruits.
GU: CVA and suprapubic tenderness on exam.
PV: Carotids – Regular, no bruits. Upper extremities warm, symmetrical in size, no lesions, no edema.
Capillary refill < 2 sec bilaterally. Lower extremities warm, symmetrical in size, even hair distribution, no
lesions, no edema, no varicosities, faint superficial vessels, toenails clear and pink. Pulses +2, regular,
equal. No lymphadenopathy. MSK: Normal ROM, joint stability normal in all extremities, no tenderness
to palpation. No scoliosis noted.
Neuro: Grossly alert and oriented x3, communication ability within normal limits, attention and
concentration normal.
Psych: Judgment and insight intact, rate of thoughts normal and logical. Pleasant, calm, and cooperative.
Patient appears to be happy/content.
Directions:
The first part of the discussion board is to identify all pertinent positive and negative information.
Would there be any other information you would want to obtain?
Then create a differential diagnosis list with at least 3 possibly actual diagnosis based on your findings.
Second part is to create a plan utilizing clinical practice guidelines for the priority diagnosis.
Be sure to include APA in-text citations and provide full reference citation at the end of the discussion.

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