Urinary Tract Infection

HISTORY:

‍Urinary symptomsDysuriaUrinary frequency for ‍ ‍hoursdays

‍dysuria

‍frequency

‍urgency

‍hematuria

‍suprapubic pain

‍flank pain

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍vomiting

‍malodorous urine

‍changes in urine color

Treatments tried: ‍none, ‍effectiveineffective



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

CVA tenderness: ‍negativepositive on Rpositive on L

Anorectal: DRE ‍normal, prostate ‍normal, anus ‍normal

Genital: ‍normal, testicles ‍normal, penis ‍normal

Pelvic: vulva ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍no cervical motion tenderness



ASSESSMENT:

‍UTI ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Urinalysis

- Urine culture

- Blood work: ‍CBC, ‍creatinine, ‍CRP

- Abdominal ultrasound

- CT scan of the abdomen and pelvis

- ‍Antibiotics

- Increase fluid intake

- Urinary tract infection prevention: voiding after intercourse, wiping front to back, avoiding irritants, avoiding retention

- Referral to urologist

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop such as fever, vomiting, or increased pain

- Go to ER if severe abdominal pain, severe vomiting, or high fever