William H Turner Technical Arts High School Urinary Tract Infection

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William H Turner Technical Arts High School

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Demographic Information Encounter Date: Patient initials: Age: Race: Gender: Insurance: Information Source: SUBJECTIVE Chief complaint: History of present illness (HPI): Allergies Medication History: Family History Patient History Past Medical History (PMH): Genetical History: Negative Infection History: Menstrual History: LMP: Menses Monthly: Prior Menses: Frequency: Menarche: On Contraception Tx: The current method of contraception is used: Menopause: Fertility: Sexual history: Obstetric History Total Preg. Full Term Premature Ab Induced Ab Espontan Ectopic Date: GA week Weigh Sex Hospitalization: History of mental illness/personality disorders: Physical trauma/falls: Surgeries: Exposure: Immunizations: Exercise: Diet: Social History: Deliver Complicity Multiple Living Educational level: Sexual Behavior: Last annual physical exam: Screening: Pap smear: HIV /STD Test: Monthly Breast Self-examination: Mammogram: Bone density: Colon cancer Screening: Skin cancer Screening: REVIW OF SYSTEM: Systemic: HEENT: Head: Neck: Cardiovascular: Respiratory: Gastrointestinal: Genitourinary: Gynecological: Breast: Endocrine: . Hematologic. Musculoskeletal: Neurological: Psychological Integumentary: OBJECTIVE: Physical Exam Vitals Signs. General appearance: Head. Neck Eyes: Ears: Nose: Oral Cavity: Pharynx: Lymph Nodes: Chest: Lungs: Cardiovascular. Abdomen: Genitourinary: Gynecological: Inspection: Palpation Speculum exam for Vagina and cervix.: Bimanual exam:. Pregnancy test Breast: Inspection: Palpation: Endocrine: Hematologic: Musculoskeletal: Neurologic: Psychiatric: Integumentary: ASSESSMENT : Main diagnosis: Differential diagnosis: 1. 2. 3. PLAN: Diagnostic tests : Pharmacological treatment: Non-pharmacological measures: Patient education: Follow-up/Referrals: Follow-up: Referrals:
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Urinary Tract Infection- Outline
I. Demographic Information
II. SUBJECTIVE
A. Chief complaint: “I have pain when I urinate and I have been going a lot lately”
B. History of present illness (HPI): 28 y/o Caucasian female presents to the clinic
with complaint of painful urination.
C. Allergies: No known allergies
D. Medication History: Tylenol 500 mg for pain
E. Family History- Negative history for cancer, cardiovascular events, and genetic
disease
F. Patient History
G. Hospitalization: No recorded previous hospitalizations
H. History of mental illness/personality disorders: None
I. REVIEW OF SYSTEM
1. Systemic: Denies unexplained weight loss, fever, or changes in appetite.
2. Head: Denies headaches, history of trauma. Denies any facial pain.
3. Musculoskeletal: No history of trauma.
4. Integumentary: Reports no bruises, lesions, rash, or itching. Denies burns,
lacerations, or history of skin cancer.
III. OBJECTIVE:
A. Physical Exam
1. Vitals Signs: Temp (Axillary): 98.1F, RR: 18 HR: 72 BP: 117/74 Ht.: 5’5”
Wt.: 145 lbs. BMI: 24.1 (normal) O2: 98% pain scale: 7/10

2. General appearance: The patient is oriented, well-dressed for weather
3. Head: Head is normocephalic, no signs of injury or trauma.
4. Cardiovascular: Normal and regular heart rhythm. S1 and S2 sounds present.
No murmurs. No edema.
5. Genitourinary: Palpation reveals no symptoms of enlarged kidneys. Bladder is
palpable and tender. Involuntary guarding associated with suprapubic pain.
IV. ASSESSMENT:
A. Main diagnosis: Acute cystitis without hematuria (N30. 00). Lower UTIs
classically present with urgency, small volumes of bladder voiding, and dysuria,
sometimes presenting with suprapubic pain.
B. Differential diagnosis:
1. Urethritis. Urethritis is similar to cystitis in that there is pain or burning with
urination.
2. Bacterial vulvovaginitis. This condition is a bacterial infection similar to
cystitis and it shares some of the symptoms including dysuria, urgency, and
frequency.
3. Acute pyelonephritis is an acute UTI ascending to the kidneys.
V. PLAN:
A. Diagnostic tests: Urinalysis and urine culture to confirm bacterial pathogen and
rule out other conditions.
B. Pharmacological treatment:
1. Amoxicillin/clavulanate (Augmentin) 500 mg PO q12H (Perez et al., 2019)
2. Ibuprofen 400 mg q8H prn

C. Non-pharmacological measures:
1. Genital hygiene
2. Adequate rest
3. STD prevention
D. Patient education:
1. Cystitis is a urinary tract infection affecting the bladder.
2. There are two classifications: Uncomplicated and complicated.
3. Cystitis can be treated using antibiotics.
C. Follow-up/Referrals- Patient should return to the clinic if symptoms are not
relieved or worsen within 72 hours.


1

Urinary Tract Infection

Name
Institution
Course
Professor
Date

2
Urinary Tract Infection
Demographic Information
Encounter Date:
Patient initials: H.F
Age:

28 y/o

Race:

Caucasian

Gender:

Female

Insurance:

PPO

Information Source: Patient
SUBJECTIVE
Chief complaint: “I have pain when I urinate a...


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