Urinary Tract Infection (demo template)

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents for ‍urinary symptomsdysuriaurinary frequency for the last ‍ ‍hoursdaysweeksmonths

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

CVA tenderness: ‍negativepositive on Rpositive on L



Urine: leuk ‍negative1+2+3+, nitrites ‍negative+, blood ‍negative1+2+3+



ASSESSMENT:

‍UTI ‍likelysuspectedpossible



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