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Princess Arianne Macaranas Seven Hello Rache Practice

Princess Arianne Macaranas Seven presented to the clinic with back pain and abnormal urination. On examination, she had lower back pain and lab results showed leukocytes, nitrites, and blood in her urine. She was diagnosed with a urinary tract infection and prescribed a 5-day course of Bactrim antibiotics. She was advised to return for follow up testing in a week.

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Dianne Macaranas
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1K views2 pages

Princess Arianne Macaranas Seven Hello Rache Practice

Princess Arianne Macaranas Seven presented to the clinic with back pain and abnormal urination. On examination, she had lower back pain and lab results showed leukocytes, nitrites, and blood in her urine. She was diagnosed with a urinary tract infection and prescribed a 5-day course of Bactrim antibiotics. She was advised to return for follow up testing in a week.

Uploaded by

Dianne Macaranas
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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1/5/22, 7:43 AM Encounter - Office Visit Date of service: 01/05/22 Patient: Princess Arianne Macaranas Seven DOB: 11/20/1998

/20/1998 PRN: SP804100

PATIENT FACILITY ENCOUNTER


Princess Arianne Macaranas Seven Hello Rache Practice NOTE TYPE SOAP Note
DOB 11/20/1998 T (520) 468-5817 SEEN BY Princess Arianne
AGE 23 yrs 4990 E Mediterranean Drive, Macaranas
SEX Unspecified Suite D, DATE 01/05/2022
PRN SP804100 Sierra Vista, AZ 85635 AGE AT DOS 23 yrs
Not signed

Chief complaint
Backpain

Patient identifying details and demographics


FIRST NAME Princess Arianne SEX Unknown RACE -
Macaranas DATE OF BIRTH 11/20/1998 ETHNICITY -
MIDDLE NAME - DATE OF DEATH - PREF. LANGUAGE -
LAST NAME Seven PRN SP804100 STATUS Active patient
SSN -
CONTACT INFORMATION
ADDRESS LINE 1 - CONTACT BY -
ADDRESS LINE 2 - EMAIL -
CITY - HOME PHONE -
STATE - MOBILE PHONE (520) 567-8912
ZIP CODE - OFFICE PHONE -
OFFICE EXTENSION -
FAMILY INFORMATION
NEXT OF KIN - PATIENT'S MOTHER'S MAIDEN -
RELATION TO PATIENT - NAME
PHONE -
ADDRESS -

Vitals for this encounter


No vitals recorded

Subjective
SUBJECTIVE
HPI-ROS:

The patient is here for backpain, she is experiencing burning sensation for over 2 to 3 weeks. She said that her urine smells weird
and contains a little blood, there is no change in color. She has no past infection or any kidney stones. She felt warm and is positive
in fever.

REVIEW OF SYSTEMS:
General: Generally healthy, no change in strength or exercise tolerance.
Head: No headaches, no vertigo, no injury.
Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain.
Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.
Nose: No epistaxis, no coryza, no obstruction, no discharge.
Mouth: No dental difficulties, no gingival bleeding, no use of dentures.
Neck: No stiffness, no pain, no tenderness, no noted masses.
Chest: No dyspnea, no wheezing, no hemoptysis, no cough.
Heart: No chest pains, no palpitations, no syncope, no orthopnea.
Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no emesis, no melena.
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1/5/22, 7:43 AM Encounter - Office Visit Date of service: 01/05/22 Patient: Princess Arianne Macaranas Seven DOB: 11/20/1998 PRN: SP804100

GU: No urinary urgency, no dysuria, no change in nature of urine.


Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias or numbness.
Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.
Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
PERSONAL, FAMILY & SOCIAL HISTORY are listed on the chart and reviewed.
Objective
OBJECTIVE
General: Experiencing loewr back pain
Head: Normocephalic, no lesions.
Eyes: Pupils equal round and reactive, extra-ocular muscles intact. Conjunctivae clear, no injection or discharge, sclera non-icteric.
Ears: EACs clear, TMs normal bilaterally.
Nose: Mucosa normal, no obstruction, no discharge.
Throat: Clear, no exudates, no lesions, no erythema.
Neck: No JVD, no masses, no thyromegaly, trachea midline, ROM normal; no meningeal signs.
Heart: Regular rhythm and rate, no murmurs, no rubs, no gallops.
Chest: Lungs clear bilaterally, no rales, no rhonchi, no wheezes, normal chest movement, no use of accessory muscles of respiration.
Abdomen: Soft, no tenderness, no masses, BS normal, no organomegaly, no bruits.
Back: Remarkable for lower back pain
Extremities: No deformities, no edema, no erythema. Range of motion WNL, pulses intact.
Neuro: No localizing findings. Mentation appropriate. Short term memory intact. Speech normal. CN 2-12 intact. No cognitive
dysfunction. No sensory or motor deficits. Gait normal.
Assessment

Diagnoses attached to this encounter:


(N39.0) Urinary tract infection, site not specified

Plan
1. The doctor get some urine specimen to test it the result shows 3+ leukocytes, positive in nitrite and also there is a presence of
little blood, doctor states the reason behind it which possibly because of dehydration, intercourse and holding urine for too long.
The patient was advised to take bactrim antibiotics for 5 days.
2. Patient must be back for a follow up check up after a week and must undergo another urinalysis.

I, Hello, MD, personally performed the services described in this documentation, as scribed by Princess Arianne P. Macaranas, RPm
in my presence, and it is both accurate and complete.

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