Assignment 5.2: Shadow health focused exam: UTI with antibiotic sensitivity
Assignment 5.2: Shadow health focused exam: UTI
with antibiotic sensitivity
Maryville University
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
, Assignment 5.2: Shadow health focused exam: UTI with antibiotic sensitivity
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.
Patient also states she has a positive view of her body and a sex-positive attitude. States she
belongs to a club on campus. Last menstrual cycle ended 2 weeks ago. States she is very good
about taking her birth control and monitors it via the 28 pill click pack.
History: Denies any relevant existing medical history.
Denies history of urinary tract infection.
Social history: Drinks alcohol about 2 nights a week, 2-3 drinks per week. States it is infrequent
and school is the priority. Denies any substance abuse.
Family history: No medical history on paternal side. On the maternal side, mother is a breast
cancer survivor. Grandmother passed of breast cancer.
Prescriptions:
Adilson Kiefer
09/29/2019
Patient: Makayla
Henderson DOB:
06/20/1998
Allergy: Penicillin
Nitrofurantoin 100mg extended release. Take 1 (one) tablet by mouth every 12 (twelve) hours for
5 (five) days. Dispense 10 (ten) tablets; no refills. Please take with meals.
Indication: Urinary Tract infection.
Phenazopyridine 200mg. Take 1(one) tablet by mouth 3 (three) times a day for 2 (two) days.
Dispense 6 (six) tablets; no refills. Please take with meals.
Patient education: Ms. Henderson was instructed to take the full course of antibiotics even she
starts feeling better and to take it with meals for absorption. Adverse effects include GI upset.
Assignment 5.2: Shadow health focused exam: UTI
with antibiotic sensitivity
Maryville University
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
, Assignment 5.2: Shadow health focused exam: UTI with antibiotic sensitivity
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.
Patient also states she has a positive view of her body and a sex-positive attitude. States she
belongs to a club on campus. Last menstrual cycle ended 2 weeks ago. States she is very good
about taking her birth control and monitors it via the 28 pill click pack.
History: Denies any relevant existing medical history.
Denies history of urinary tract infection.
Social history: Drinks alcohol about 2 nights a week, 2-3 drinks per week. States it is infrequent
and school is the priority. Denies any substance abuse.
Family history: No medical history on paternal side. On the maternal side, mother is a breast
cancer survivor. Grandmother passed of breast cancer.
Prescriptions:
Adilson Kiefer
09/29/2019
Patient: Makayla
Henderson DOB:
06/20/1998
Allergy: Penicillin
Nitrofurantoin 100mg extended release. Take 1 (one) tablet by mouth every 12 (twelve) hours for
5 (five) days. Dispense 10 (ten) tablets; no refills. Please take with meals.
Indication: Urinary Tract infection.
Phenazopyridine 200mg. Take 1(one) tablet by mouth 3 (three) times a day for 2 (two) days.
Dispense 6 (six) tablets; no refills. Please take with meals.
Patient education: Ms. Henderson was instructed to take the full course of antibiotics even she
starts feeling better and to take it with meals for absorption. Adverse effects include GI upset.
