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Urinary Tract Infection (demo template)
Age:
years old
Gender:
male
female
HISTORY:
Presents for
urinary symptoms
for the last
hours
days
weeks
months
dysuria
frequency
urgency
hematuria
suprapubic pressure
flank pain
fever
up to
°
chills
vomiting
recurrent UTIs
recent urinary catheterization
past kidney stones
diabetes
EXAM:
General appearance:
well-appearing
Vital signs:
normal
,
BP
,
HR
,
RR
,
SpO2
%
,
Temp
°
Abdomen:
soft
,
non-tender
,
non-distended
,
CVA tenderness:
negative
Urine: leuk
negative
, nitrites
negative
, blood
negative
ASSESSMENT:
UTI
likely
suspected
possible
PLAN:
- Urinalysis
- Urine culture
- Abdominal ultrasound
-
Select antibiotics →
- Prevention discussed: voiding after intercourse, wiping front to back, avoiding irritants, avoiding retention, increasing fluid intake
- Return if does not improve or if new symptoms develop such as fever, vomiting, or increased pain