Chapter 12: The Urinary System | Shara Brown's Chart Note

CHART NOTE

Patient Name: Brown, Shara
ID Number: 89736
Examination Date: October 1, 20xx

SUBJECTIVE
Shara presents with frequency, urgency, fever, and burning upon urination for 3-5 days accompanied by malaise, flank pain, hematuria, and renal colic. She delayed care until completion of final exams. Patient has a history of multiple bladder infections.

OBJECTIVE
BP (blood pressure) 120/80, pulse 76, respirations 22/min. Dipstick urinalysis showed yellow urine, cloudy with 80-100 WBCs (white blood cells), and many bacteria.

ASSESSMENT
UTI and cystitis.

TREATMENT PLAN
Cephalexin 500 mg p.o. t.i.d. x 10 days (take one 500-mg tablet of the antibiotic cephalexin by mouth 3 times a day for 10 days). Recommend follow-up with urologist. Chronic cystitis vs. pyelonephritis.