= YES = NO ✓ ✗ ( PLACE PATIENT LABEL HERE) SURNAME: ____________________________________ NHI: _____________ FIRST NAMES: ____________________________________________________ Date of Birth: _______ /_______ /_______ SEX: _____________ 1 URINARY SYMPTOMS IN ADULTS (Suspected Urinary Tract Infection - UTI) Date: / / 20 Tim me: Clinician: NP CNS HS Re eg g SMO HISTOR RY, PRESENTING G COMPLAINT & SYSTEM MS REVIEW Unwell fo or : GU: Dysuria Frequency Supra-pubic pain n Haematuria Gen: Fever / rigors Nausea / vomitin ng Flank / back pain n GI: Abdominal pain STI risk Sexually active Previous STI PV / penile disch harge Prostatitis Rectal / perineal pain pain RELEVA ANT MEDICAL & SURGICAL HISTORY Ni il relevant Immun nosupression Pregna ant IDDM / NIDDM Previo ous UTI / urosepsis IDUC / instrumentation RELEVA ANT MEDICATION NS / ALLERGIES Ni il regular Nil kno own allergies ALLERGIES: FUNCTI IONAL & SOCIAL L HISTORY Ni il relevant ADL Independent Smoking Non smoker Smoker: ETOH Hx EMERGENCY MEDICINE NOTES 7.7.210 B 09/2017
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URINARY SYMPTOMS IN ADULTS - Hospitals & Health … · URINARY SYMPTOMS IN ADULTS (Suspected Urinary Tract Infection - UTI) Date: / / 20 Time: Clinician: NP CNS HS Reg SMO HISTORY,
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HISTORY, PRESENTING COMPLAINT & SYSTEMS REVIEWHISTORY, PRESENTING COMPLAINT & SYSTEMS REVIEWHISTORY, PRESENTING COMPLAINT & SYSTEMS REVIEWHISTORY, PRESENTING COMPLAINT & SYSTEMS REVIEWHISTORY, PRESENTING COMPLAINT & SYSTEMS REVIEWHISTORY, PRESENTING COMPLAINT & SYSTEMS REVIEWHISTORY, PRESENTING COMPLAINT & SYSTEMS REVIEWHISTORY, PRESENTING COMPLAINT & SYSTEMS REVIEWUnwell for : Unwell for : Unwell for : Unwell for : Unwell for :
GU: Dysuria Frequency Supra-pubic pain Supra-pubic pain Haematuria
Gen: Fever / rigors Nausea / vomiting Nausea / vomiting Flank / back pain Flank / back pain
GI: Abdominal painSTI risk Sexually active
Previous STI PV / penile discharge PV / penile discharge
RELEVANT MEDICAL & SURGICAL HISTORY RELEVANT MEDICAL & SURGICAL HISTORY RELEVANT MEDICAL & SURGICAL HISTORY RELEVANT MEDICAL & SURGICAL HISTORY RELEVANT MEDICAL & SURGICAL HISTORY Nil relevant Nil relevant Nil relevant Immunosupression Immunosupression Pregnant Pregnant IDDM / NIDDM IDDM / NIDDM Previous UTI / urosepsis Previous UTI / urosepsis IDUC / instrumentation IDUC / instrumentation
Nil known allergies Nil known allergies ALLERGIES:FUNCTIONAL & SOCIAL HISTORY FUNCTIONAL & SOCIAL HISTORY FUNCTIONAL & SOCIAL HISTORY FUNCTIONAL & SOCIAL HISTORY FUNCTIONAL & SOCIAL HISTORY Nil relevant Nil relevant Nil relevant
FIRST NAMES: ____________________________________________________
Date of Birth: _______ /_______ /_______ SEX: _____________
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EXAMINATIONEXAMINATIONEXAMINATIONEXAMINATION
CVS Warm and well perfused Warm and well perfused
Cap refill Normal
Pulses Normal
Respiratory
Breathing work Normal
Breath sounds Vesicular
Abdominal
Appearance Not distended Distended
Palpation Soft Tender
Guarding No Yes:
Rebound tender No Yes:
Renal angle tender No Yes:
Organomegaly None
Bowel sounds Normal
♀ Vaginal examination Look for signs of infection♀ Vaginal examination Look for signs of infection♀ Vaginal examination Look for signs of infection♀ Vaginal examination Look for signs of infection Not indicated
Indications: PV discharge or unilateral abdominal painIndications: PV discharge or unilateral abdominal painIndications: PV discharge or unilateral abdominal pain Performed by: Dr _______________________________Performed by: Dr _______________________________Urinary meatus Normal Discharge Lesions: describe:
Cervix Normal Motion tender Swabs sent x 3
Adnexae Not tender TenderPalpable mass No Yes:
♂ Genital examination: Always rule out STI in all sexually active men♂ Genital examination: Always rule out STI in all sexually active men♂ Genital examination: Always rule out STI in all sexually active men♂ Genital examination: Always rule out STI in all sexually active men Not indicated
Indications: PV discharge or unilateral abdominal painIndications: PV discharge or unilateral abdominal painIndications: PV discharge or unilateral abdominal pain Performed by: Dr _______________________________Performed by: Dr _______________________________External genitalia Normal Discharge Swabs sent Swabs sent
Lesions:
Testes Normal
Prostate Normal Tender Irregular
VITAL SIGNS
Within normal limits
VITAL SIGNS
Within normal limits
BP ______________ mmHgBP ______________ mmHg Resp Rate _________ minResp Rate _________ min Pain score _____ /10Pain score _____ /10VITAL SIGNS
Within normal limits
VITAL SIGNS
Within normal limitsPulse ______________ bpmPulse ______________ bpm SPO2 ______________ %SPO2 ______________ %
VITAL SIGNS
Within normal limits
VITAL SIGNS
Within normal limitsTemp ______________ ℃Temp ______________ ℃ Air NP Hudson: ____ l/min Air NP Hudson: ____ l/min Air NP Hudson: ____ l/min Air NP Hudson: ____ l/min
Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair
PREVIOUS URINE CULTURESPREVIOUS URINE CULTURES Not applicableDate:
Antibiotics WDHB antibiotic guidelines page 4 Best Care Bundle PathwayWDHB antibiotic guidelines page 4 Best Care Bundle Pathway
Analgesia
IV fluids
Disposition Discharge EDS proforma (link from EDS) already pre-populated with patient informationEDS proforma (link from EDS) already pre-populated with patient informationEDS proforma (link from EDS) already pre-populated with patient information