HISTORY:
for
, up to °, over
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
CVA tenderness:
Anorectal: DRE , prostate , anus
Genital: , testicles , penis
Pelvic: vulva , vagina , cervix , uterus , adnexa ,
ASSESSMENT:
DDx:
PLAN:
- Urinalysis
- Urine culture
- Blood work: , ,
- Abdominal ultrasound
- CT scan of the abdomen and pelvis
-
- Increase fluid intake
- Urinary tract infection prevention: voiding after intercourse, wiping front to back, avoiding irritants, avoiding retention
- 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