Assignment 5.2: Shadow health focused exam: UTI with antibiotic sensitivity
Synopsis
Patient: Makayla Henderson
DOB: 06/20/1998
Allergy: Penicillin (Red, itchy rash, nausea and vomiting)
Scenario: Ms. Henderson is a 21-year-old biracial woman who has come to the university health
clinic complaining about urination issues.
Diagnosis: Uncomplicated UTI
Urinalysis: Urine dipstick positive for nitrites/leukocyte esterase
Pregnancy test: Negative
Home medications: - Norgestimate/ethynyl/estradiol combo PO once daily
- Loratadine 10 mg once daily
- Cranberry pills 2 tabs daily
Vitals: Temp 37F (Temporal), Blood pressure 117/78 (Automatic), Heart rate 80 (NSR) , O2 sat:
99% (room air).
Local microbial resistance: Sulfamethoxazole/trimethoprim at 35%
Assessment: Ms. Henderson states she has been having frequent urination causing burning and
pain. The describes the urine as dark/brown and cloudy and states her symptoms started about 3
days ago. Patient has been avoiding drinking water in order to minimize going to the bathroom
due to pain and burning during urination. There is stinging and burning pain 7 out 10 at the
external orifice of the urethra accompanied by cramping in the lower abdomen. Denies and any
fatigue, fever or holding urine for long periods of time. When questioned about her sexual
history, she states she had sex 4 days ago and had a single partner for a period of time now.
Synopsis
Patient: Makayla Henderson
DOB: 06/20/1998
Allergy: Penicillin (Red, itchy rash, nausea and vomiting)
Scenario: Ms. Henderson is a 21-year-old biracial woman who has come to the university health
clinic complaining about urination issues.
Diagnosis: Uncomplicated UTI
Urinalysis: Urine dipstick positive for nitrites/leukocyte esterase
Pregnancy test: Negative
Home medications: - Norgestimate/ethynyl/estradiol combo PO once daily
- Loratadine 10 mg once daily
- Cranberry pills 2 tabs daily
Vitals: Temp 37F (Temporal), Blood pressure 117/78 (Automatic), Heart rate 80 (NSR) , O2 sat:
99% (room air).
Local microbial resistance: Sulfamethoxazole/trimethoprim at 35%
Assessment: Ms. Henderson states she has been having frequent urination causing burning and
pain. The describes the urine as dark/brown and cloudy and states her symptoms started about 3
days ago. Patient has been avoiding drinking water in order to minimize going to the bathroom
due to pain and burning during urination. There is stinging and burning pain 7 out 10 at the
external orifice of the urethra accompanied by cramping in the lower abdomen. Denies and any
fatigue, fever or holding urine for long periods of time. When questioned about her sexual
history, she states she had sex 4 days ago and had a single partner for a period of time now.
