Sample Name: Foul-Smelling Urine
Description: Foul-smelling urine and stomach pain after meals.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Foul-smelling urine and stomach pain after meals.
HISTORY OF PRESENT ILLNESS: Stomach pain with most meals x one and a half years and urinary symptoms for same amount of time. She was prescribed Reglan, Prilosec, Pepcid, and Carafate at ED for her GI symptoms and Bactrim for UTI. This visit was in July 2010.
REVIEW OF SYSTEMS: HEENT: No headaches. No visual disturbances, no eye irritation. No nose drainage or allergic symptoms. No sore throat or masses. Respiratory: No shortness of breath. No cough or wheeze. No pain. Cardiac: No palpitations or pain. Gastrointestinal: Pain and cramping. Denies nausea, vomiting, or diarrhea. Has some regurgitation with gas after meals. Genitourinary: "Smelly" urine. Musculoskeletal: No swelling, pain, or numbness.
MEDICATION ALLERGIES: No known drug allergies.
Neck: No nodes. No thyromegaly. No masses.
Heart: Regular rate without murmur.
Abdomen: Soft, without organomegaly, without guarding or tenderness.
Back: Straight. No paraspinal spasm.
Extremities: Full range of motion. No edema.
Neurologic: Cranial nerves II-XII intact. Deep tendon reflexes 2+ bilaterally.
4. Contraception consult.
1. Cipro 500 mg b.i.d. x five days. Ordered BMP, CBC, and urinalysis with microscopy.
3. Prescriptions same as #2. Also referred her for a barium swallow series to rule out a stricture.
4. Ortho Tri-Cyclen Lo.
Keywords: urology, foul-smelling urine, stomach pain, uti, gerd, dysphagia, contraception,