Chapter 12: The Urinary System | Elizabeth Townsend's Chart Note

CHART NOTE

Patient Name: Townsend, Elizabeth
ID Number: 12333
Examination Date: February 23, 20xx

SUBJECTIVE
This 14-year-old female presents with urinary frequency and incontinence for the past 2 days. She has had pain on urination for the past 3–5 days; no hematuria noted. No flank pain. Patient did complain that her stomach hurt. Fever of 101° for the past 24 hours. No vomiting. Patient has a history of a urinary tract infection several months ago; however, no repeat urinalysis was performed. She has not had an intravenous pyelogram or renal ultrasound. Family history is significant; paternal grandmother had a nephrectomy.

OBJECTIVE
Alert and in no distress. Abdomen is soft with no masses, tenderness, or hepatosplenomegaly (enlargement of the liver and spleen). No guarding (a reflexive response to protect an area of pain).

LABORATORY
Urinalysis shows 60–80 WBCs (white blood cells) and 80–100 RBCs (red blood cells) and positive nitrates.

ASSESSMENT
Recurrent UTI.

TREATMENT PLAN
Ciprofloxacin 500 mg b.i.d. x 10 days (take 500 mg of ciprofloxacin twice a day for 10 days). Obtain urine C&S. Repeat urinalysis and urine culture 2 days after completion of antibiotics. Follow up with renal ultrasound.