Professional Documents
Culture Documents
Thorax and lungs: Breath sounds are clear and normal. No adventious breath sounds.
Cardiovascular: No murmur, gallops, rubs or extra heart sounds. No thrills, heaves or lifts. S1, S2
present.
Gastrointestinal: Abdomen soft and non-tender to touch, positive bowel sounds present.
GU: Suprapubic area tender to touch, No CVA tenderness.
Lab:
1. Dipstick urinalysis- positive for nitrite and leukocyte esterase positive
2. Urine Culture
Impression/Planning:
Diagnosis: Urinary tract infection, site not specified (ICD 9 599.0)
2. Screening for cervical cancer: Educate patient that she should get her pap test every 3 years to
screen for cervical cancer. Her last pap test was in 09/2013, normal, so advise her to schedule her
next pap test in 09/ 2016.
3. Encourage her to get well-women visit once a year and her blood pressure checked at least one
every 2 years (HHS, 2014)
4. Educate her about the importance of flu shot and its side effect and advise her to get it every
year to prevent flu.
5. Educate patient to go for dental visit twice a year or every 6 months (Vorvick, 2012).
6. Advise patient to get tested for HIV at least once.
7. Educate her that based on her family history for heart disease and her risk for heart disease
(diabetes, smoking, high blood pressure, and obesity) she might need to get her blood cholesterol
checked once every 5 years (HHS, 2014).
8. Teach patient to get her eye examined every two years (Vorvick, 2012).
References
Domino, F.J. (2014). The 5-Minute clinical consult (22nd ed.). Philadelphia, PA:
Lippincott Williams & Wilkins.
Intelihealth. (2014). urinary tract infections in women. Retrieved from
http://www.intelihealth.com/article/urinary-tract-infection-in-women
Patel, B.N, Lee,.U.J., & Goldman,H.B. (2013). Urinary tract infections in women. Retrieved
from htps://online.epocrates.com/noFrame/showPage.do?method=diseases
&MonographId=77&ActiveSectionId=11
U.S. department of health & human services (HHS). (2014). Healthfinder.gov. retrieved from
http://healthfinder.gov/myhealthfinder/Result.aspx?
age=30&gender=female&pregnant=f
alse
Vorvick, L.J. (2012). Health screening - women - age 18 39. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/007462.htm