Urology Case Studies

EMERGENCY ROOM REPORT

She presents complaining of lower abdominal pain, worse on the right, since approximately 0300 hours.  She denied any vaginal bleeding.  She, however, was experiencing increased frequency and indicated she has had at least 3 urinary tract infections during the preceding year.  She took 1 Pyridium as well as Bactrim from an old prescription prior to this episode and also experienced an episode of vomiting during the preceding few hours.

Physical assessment revealed suprapubic tenderness with bowel sounds being somewhat hyperactive.  No rebound or guarding.  No flank pain with percussion.

LABORATORY

Urinalysis which did reveal 80 to 100 white blood cells per
high-power field and the presence of a few bacteria.

IMPRESSION

Impression is urinary tract infection.

PLAN

Prescription was written for the above-mentioned medications.

FOOTNOTE

Line 19.  The physician dictated Plan but probably meant Laboratory, since lab values follow.

Line 20.  Alternative:  80-100.

Line 21.  The dictation error was corrected to high-power field.

Line 23.  The heading Impression was added.

Line 27.  Rx was translated as Prescription.