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Notes

History
  • Kidney stones, blood in urine, dysuria, voiding pattern changes, itching, cancer (e.g., prostate, cervix, ovarian), UTI.
  • Sexual history: Sexual activity, use of protection against infection, method of birth control, multiple or same-sex partners, history of STD, ED (male Pts).
Medication
  • Antibiotics, antifungals, antispasmodics, phosphodiesterase inhibitors (Viagra, Cialis, Levitra), analgesics.
Pain
  • History of painful or burning urination?
  • Female:Dysmenorrhea (abnormally severe cramping during menstruation).
  • Male: Penis, testes, scrotum, and groin.
Lesions
  • Blisters, ulcers, sores, warts, or rashes.
Breasts
  • Symmetry, dimpling or edema, nipples (color, discharge, or inversion).
  • Lumps or tenderness (palpate in a concentric circle, outward from nipple, including axillae), presence of implants.
  • Breast self-exams?
Testicles
  • Lumps, masses, or swelling (palpate scrotum and groin area).
  • Testicular self-exams?
Discharge
  • Female: Assess for vaginal discharge and note color, odor, amount, and any associated symptoms.
  • Male: Inspect meatus for discharge and note color, amount, and any associated symptoms.
Menstruation
  • Describe last period including date.
  • Do periods occur regularly?
  • Investigate bleeding other than normal period (frequency, quantity, symptoms).