Name ____________________________________________Class_________Date
____/____/____
S: cc:_____________________________________________________________________________________
| Symptoms | yes | no | duration / location / character |
| dysuria | |||
| frequency | |||
| urgency | |||
| nocturia | |||
| hematuria | |||
| back pain | |||
| abd. pain | |||
| fever/chills | |||
| vag.discharg | |||
| other |
| sex.active? | (if yes,BC method?) | LMP? |
Additional Hx. _________________________________________________________________________________________
______________________________________________________________________________________________________
| PMH | UTI's | pyelo | STD's | PID | GU surg/abnormal. | other __________ |
| yes | ||||||
| no |
Current meds? _____________________________________________________________________________________
Med. allergies?_______________________________________________________________________________________
| O: temp___ | WNL | ABN | |
| appear | |||
| back/CVA | |||
| Abd |
Pelvic Exam if needed
| ext.genit | |||
| speculum | |||
| bimanual |
over
Dickinson College Student
Health Services UTI/GU (pg 2)
Name ________________________________________________________________________________
Class__________
LABS:
| Dipstix | Leu | Nit | Urobi | Prot | pH | Bl | SpGr | Ket | Bili | Glu |
| Micro | color | Charac | WBC | RBC | Bact | Epi | other | acceptable |
| contaminated |
| KOH/WP | Yeast | WBC | RBC | Bacteria | Clue Cells | Trich | other |
A: UTI Pyelonephritis Other ____________________________________________
P: Bactrim DS 1 po BID X 3 days / 10 days Amoxicillin 250 mg 1 po TID X 10 days
Cephalexin (Keflex) 250mg QID / 500 mg BID X 10 days Macrodantin 50 / 100 mg QID X 7 days
Cipro 250 / 500 mg Q12 hrs Ofloxacin 200 mg Q12 hrs.
Pyridium 100 mg 2 TID after meals
Referred
to__________________________________
LABS REFERRED: None
UA
Culture Pap Chlamydia
Herpes
GC
Health Education
Warned of possible effects of antibiotics on oral contraceptives
Instructions: inc.fluids, void p intercourse, hygiene, UTI handout
RTC __________________________ RTC
PRN
_____/_____/_____ ________ _____________________________________________________
date time Provider's signature
_______________________________________________________________________________________
_______________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
\FORM\uti.cck REV:10/16/99 MAP