|
HPI
|
|
|
Severity*
|
Moderate. No fevers.
|
|
Course*
• • •
|
Onset: *
• • •
|
|
Fever?
|
Associated symptoms.
• • •
|
|
Additional notes
|
Similar to prior episodes of UTIs.
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
GU (positive)
• • •
|
GU (negative)
• • •
|
|
Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
Insert ROS Macro Here
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
Abdomen: + suprapubic TTP
|
|
|
GI (positive)
• • •
|
Abdomen (negative)
• • •
|
|
Additional abdomen findings
|
|
|
No CVA tenderness.
|
+CVAT
|
|
PE: Superficial
|
PE: Head to toe exam
|
|
Insert Macro Here
|
|
|
|
|
|
MDM
|
Clinic Visit CPT CODE***
|
|
DDx (Female) dysuria vs UTI vs pregnancy vs ureteral stone vs pyelonephritis
|
DDx (male) dysuria vs UTI vs ureteral stone vs pyelonephritis
|
|
MDM Notes
|
|
|
Status:
|
Diagnosis:
• • •
|
|
Status:
|
Diagnosis:
|
|
Status:
|
Diagnosis:
|
|
Status:
|
Diagnosis:
|
|
DISCHARGE
|
|
|
POC Medications Given
• • •
|
|
|
Discharge pt home
|
Discharge Note: ERD ONLY
|
|
Plan Notes
|
|
