Assignment 5.2 UTI with Antibiotic Sensitivity : Makayla Henderson

Assignment 5.2: Shadow health focused exam: UTI with antibiotic sensitivity

Synopsis

Patient: Makayla Henderson

DOB: 06/20/1998

Allergy: Penicillin (Red, itchy rash, nausea and vomiting)

Scenario: Ms. Henderson is a 21-year-old biracial woman who has come to the university health

clinic complaining about urination issues.

Diagnosis: Uncomplicated UTI

Urinalysis: Urine dipstick positive for nitrites/leukocyte esterase

Pregnancy test: Negative

Home medications: - Norgestimate/ethynyl/estradiol combo PO once daily

- Loratadine 10 mg once daily

- Cranberry pills 2 tabs daily

Vitals: Temp 37F (Temporal), Blood pressure 117/78 (Automatic), Heart rate 80 (NSR) , O2 sat:

99% (room air).

Local microbial resistance: Sulfamethoxazole/trimethoprim at 35%

Assessment: Ms. Henderson states she has been having frequent urination causing burning and

pain. The describes the urine as dark/brown and cloudy and states her symptoms started about 3

days ago. Patient has been avoiding drinking water in order to minimize going to the bathroom

due to pain and burning during urination. There is stinging and burning pain 7 out 10 at the

external orifice of the urethra accompanied by cramping in the lower abdomen. Denies and any

fatigue, fever or holding urine for long periods of time. When questioned about her sexual

history, she states she had sex 4 days ago and had a single partner for a period of time now.

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