URINARY SYMPTOMS IN ADULTS - Hospitals & Health … · URINARY SYMPTOMS IN ADULTS (Suspected...
Transcript of URINARY SYMPTOMS IN ADULTS - Hospitals & Health … · URINARY SYMPTOMS IN ADULTS (Suspected...
= YES = NO ✓ ✗
(PLACE PATIENT LABEL HERE)
SURNAME: ____________________________________ NHI: _____________
FIRST NAMES: ____________________________________________________
Date of Birth: _______ /_______ /_______ SEX: _____________
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URINARY SYMPTOMS IN ADULTS(Suspected Urinary Tract Infect ion - UTI)
Date: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMO
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
Prostatitis Rectal / perineal pain pain Rectal / perineal pain pain
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
RELEVANT MEDICATIONS / ALLERGIES RELEVANT MEDICATIONS / ALLERGIES RELEVANT MEDICATIONS / ALLERGIES RELEVANT MEDICATIONS / ALLERGIES RELEVANT MEDICATIONS / ALLERGIES Nil regular Nil regular Nil regular
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
ADL Independent Smoking Non smoker Smoker:
ETOH Hx
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(PLACE PATIENT LABEL HERE)
SURNAME: ____________________________________ NHI: _____________
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
General NOT distressed
Pain None Mild Moderate Severe
Dehydration None Mild Moderate Severe
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SURNAME: ____________________________________ NHI: _____________
FIRST NAMES: ____________________________________________________
Date of Birth: _______ /_______ /_______ SEX: _____________
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RESULTS RESULTS RESULTS RESULTS RESULTS RESULTS RESULTS RESULTS RESULTS RESULTS RESULTS RESULTS HAEMATOLOGYHAEMATOLOGY BIOCHEMISTRYBIOCHEMISTRYBIOCHEMISTRYBIOCHEMISTRYBIOCHEMISTRYBIOCHEMISTRY URINE: DipstixURINE: Dipstix MSU / CSUMSU / CSU
Hb Na+ CRP Leuc Est WCC
PL K+ β-HCG Nitrites RCC
WCC Gluc Prot Epi’s
Creat Bact
Lipase
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:
Bacteria:
Sensitivities:
Resistance:
SWAB RESULTS Not applicable
Site(s):Site(s):Site(s):Site(s):Site(s):
OTHEROTHEROTHEROTHER
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SURNAME: ____________________________________ NHI: _____________
FIRST NAMES: ____________________________________________________
Date of Birth: _______ /_______ /_______ SEX: _____________
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Clinician Name: Designation: Sign: Contact details: _________
For junior staff: Discussed with Reviewed by SMO Dr : _____________________ Sign: __________
CLINICAL IMPRESSION CLINICAL IMPRESSION CLINICAL IMPRESSION CLINICAL IMPRESSION CLINICAL IMPRESSION Diagnosis Uncomplicated UTI Uncomplicated UTI DDx includes:
See definitions page 3
Best Care Bundle Pathway
Pyelonephritis Upper UTI Pyelonephritis Upper UTI See definitions
page 3 Best Care Bundle
Pathway
Urosepsis UrosepsisSee definitions
page 3 Best Care Bundle
Pathway Catheter associated UTI Catheter associated UTI
See definitions page 3
Best Care Bundle Pathway
Other: Other:
PLAN / NURSING INSTRUCTIONSPLAN / NURSING INSTRUCTIONSPLAN / NURSING INSTRUCTIONSPLAN / NURSING INSTRUCTIONSPLAN / NURSING INSTRUCTIONS
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
Inpatient admission: D/W Dr: _________________ Specialty: _____________ Time: _______ Inpatient admission: D/W Dr: _________________ Specialty: _____________ Time: _______ Inpatient admission: D/W Dr: _________________ Specialty: _____________ Time: _______ Inpatient admission: D/W Dr: _________________ Specialty: _____________ Time: _______
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