Sample Nursing Case Studies

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CC Melissa is a 21-year-old female here today complaining of a possible urinary tract infection. HPI The patient tells me her symptoms started about two days ago. She has noticed burning, particularly at the end of urination. She has had urinary frequency, but says this is not completely out of the ordinary for her, because she drinks lots of water. She has had some urgency and dysuria, as well as the feeling of incompletely emptying her bladder. She has been drinking lots of fluids, as mentioned. There have been no fevers or back pain. No belly pain. No discharge. She is not currently concerned for STDs. She did take a home UTI test yesterday and reports that it was normal. She is using condoms for STD and birth control protection.…show more content…
O Vital Signs Temperature: 98.2. BP: 116/74. HR: 70. R: 12. W: 161. General A well-developed, well-nourished female in no acute distress, seated comfortably in the exam room. She is alert and oriented. Very pleasant. Appears nontoxic. Abdomen Soft and nontender. No masses or discomfort. There is suprapubic tenderness. No CVA tenderness. A urine screen done in the office shows less or equal to 1.005 specific gravity, moderate blood, moderate leukocyte esterase. A/P Melissa Opalka is a 21-year-old female here today with cystitis symptoms. We did talk about treatment options. She was written for Macrobid one p.o. twice daily #10 with no refills, as well as Pyridium 200 mg three times daily as needed #6 with no refills. I reviewed the use and side effects of both medications with her. She knows a urine culture will be sent and she will be contacted by the end of the week regarding that. Certainly, if she is not feeling better, she should call before the weekend, so we can make adjustments, if necessary. Otherwise, she will await the phone call. She was comfortable this plan. I have encouraged her to continue to use 100% of the time condoms. If she develops other symptoms with discharge or pain, and she feels she needs more evaluation, she will return to the office to see myself or Dr. Lilly. All questions were answered in the office

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