This patient is seen in the clinic at the request of Dr. Jones for evaluation of suprapubic pain. Patient is a 22-year-old black female G1 P0, LMP 12/20/xx, EDC 10/16/xx by 14-week ultrasound taken on 4/16/xx, 18 weeks with twin gestation. Presents with complaint of suprapubic sharp to mild pain with onset 2 months ago. Pain has become progressively worse. Patient has been seen by Dr. Jones for this pregnancy and has also been seen by Dr. Smith for this current complaint 2 weeks ago. Patient denies urgency and frequency of nocturia, denies hematuria, and denies discharge.
Labs: CBC and urinalysis performed.
Allergies: none. Past medical history: genital wart 1986.
Past surgical history: wart removed by laser 1986.
Social history: no smoking, illicit drugs, or alcohol.
PE: During an expanded problem-focused examination, the HEENT was found to be normal.
FHT: A 148, B 146.
Abdomen: gravid 20 cm. Slight tender suprapubic region.
Vaginal exam: closed cervix, thick, long; no discharge.
Extremities: negative for edema; UA loaded with bacteria and WBC.
Impression: 1. IUP at 18 weeks with twin gestation. 2. Acute UTI (the MDM was straightforward).
Recommendation: Keflex, 500 mg, and follow-up with Dr. Jones