HISTORY:
for
, up to °, over
, episodes , ,
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
CVA tenderness:
Pelvic: vulva , vagina , cervix , uterus , adnexa ,
Genital: , testicles , penis
Skin:
Extremities: , , cap refill , pulses ,
Thoracic
Lumbar spine: on , range of motion
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , ,
- Urinalysis
- Urine culture
- Abdominal ultrasound
- CT scan of abdomen
- CT pyeloscan
-
-
- Increase fluid intake
- Referral to urologist
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as fever, vomiting, or increased pain
- Go to ER if severe abdominal pain, severe vomiting, or high fever