CC: T.S is a 36-year-old female who presents to the clinic with a recurring urinary tract infection History of Present Illness (HPI): T.S is a 36-year-old female complaining of a recurring urinary tract infection.

CC: T.S is a 36-year-old female who presents to the clinic with a recurring urinary tract infection

History of Present Illness (HPI): T.S is a 36-year-old female complaining of a recurring urinary tract infection. According to the patient, she was diagnosed of cystitis few years ago  and was treated. Following that, she has been well until about a  year when she began experiencing episodes of urinary tract infection, with some being severe.

She indicated that she has an urgency to urinate (about 4 to 6 times a day) with severe burning sensations when the urine hits the skin with occasional vaginal discharges. She could only urinate in small amounts (less than 50ml per hour) each time she feels the urge to urinate. T.S increased her intake of fluids and cranberry juice as previously advised by her former PCP during her initial episodes of UTI in an attempt to help relieve the pains and facilitate her urine flow, but she had seen no noticeable change. She denies any nausea, fever, chills and vaginal bleeding this time.

Patient denies any other past medical history except cystitis. She has been through three Cesarean sections for her three children. She is currently not on any medication but takes some pain reliefs (acetaminophen) when she gets so exhausted from work. T.S denies the history of kidney stones and ulcers. She has not been admitted at the hospital over any ailment in the past five years. The patient carries out a routine medical checkup once a year.

Upon arrival at our clinic, the patient was in severe abdominal pain and had an urge to empty her bladder but when she went to the restroom, she peed just about 20 ml (per patient). In view of that, her urine and blood samples were collected to be analyzed in the laboratory. The patient indicated that she has been feeling well, no burning sensation and adequate urine flow until she had sexual intercourse with her partner. The pains began the following morning and with that, she believes her intercourse might have triggered her pains. T.S was primarily diagnosed with chronic urinary tract infection taking evidence from her in house urinalysis.

Past Medical History (PMH): T.S has a past medical history of cystitis. Patient has never been diagnosed with any other medical history.

Past Surgical History (PSH): Patient has had three cesarean sections for all of her children. Medications (MEDS): Multivitamin (one a day) and Acetaminophen (500mg)

Allergies/Reactions (All/RXNs): NKDA.  Patient is allergic to corn based foods and suffers wheezing and shortness of breath if she consumes such foods. Patient is lactose intolerant.

Social History (SH): Patient is married with three children.  She works with a traveling agency that gives them opportunities to travel a lot.

Family History: T.S has a family history of diabetes. Her father and two siblings were diabetic patients in their mid-forties. She further indicated that, her father’s siblings as well as her grandfather (father’s father) were all diagnosed of type 2 diabetes at some stage of their life but were effectively managed with medications and none had ever been put on insulin injection.

Smoking: Patient was a smoker but quit at age 20.

Alcohol: Denies use of alcoholic beverage

Substance use: Denies illicit drugs

Military Service: A non-veteran

Review of Systems (ROS)

General: Patient complains of fatigue and abdominal pains but denies chills, fever and any recent weight loss. She also denies loss of appetite.

Skin: Patient denies any skin rashes, itching, ulcers, any change in skin color, open areas or bruising.

Hair Patient denies any hair loss. Patient’s hair appears uniform in texture.

Head: Patient denies any head trauma, vertigo or fainting.

Eyes: Patient complains of photophobia when driving at night without glasses. She also mentions the need to use shades when walking outside on a sunny day else her eyes become teary.  She denies blurred vision, itching, discharge and pains. Date of last eye exams was 12/21.

Ears: Patient denies any hearing loss or changes or vertigo.

Nose: Denies any sinus problems, epistaxis and nasal congestion or dental problems.

Mouth: Patient denies oral lesions, dental caries and gum bleeding. Date of the last dental exams was 12/21.

Throat: Patient denies any sore throat, throat dryness and difficulty in swallowing.