PRAC 6552 Week 3 Assignment 2: Episodic Visit: Gynecology Focused Note

(PRAC 6552 Week 3 Assignment 2, PRAC 6552 Week 3 Assignment 2)

Patient Information: 

Patient Initials: E.W.               Age: 54                       Gender: Female                       Race: White

Subjective Data: 

CC:

HPI: 54-year-old white female presents to clinic for a well woman’s exam. Patient states she has a new boyfriend and is having pain during intercourse. Patient reports the pain during sex feels like a lot of pressure and sometimes burns. She states she also has been having issues with frequent urination. She has been taking her oxybutynin to help with peeing so much with little to no relief. She rates her pain during intercourse a 5/10. Entered menopause at age 51.

Current Medications:

• Oxybutynin 5mg PO TID
• ProAir HFA 90 mcg/inh inhalation aerosol, 2 puffs QID prn coughing/shortness of breath
• Spiriva 18mcg INH daily

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