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 u... niversity 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 CONTINUED...... [Show More]
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