Urinary Tract Infection (demo template)

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents for  urinary symptoms  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:  soft ,  non-tender  ‍,  non-distended , ‍

CVA tenderness:  negative 



Urine: leuk  negative , nitrites  negative , blood  negative 



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