UTI/vaginal symptoms

onset

hours days weeks months years sudden gradual

new?

new issue previously known issue

urinary symptoms

none + dysuria – + frequency – + hematuria – + foul smell – + cloudy urine –

vaginal symptoms

none + clear/white discharge – + yellow discharge – + brown discharge –
+ pruritus – + dyspareunia –

intensity

mild mild-moderate moderate moderate-severe severe

status

improving unchanged resolved gradually worsening significant worsening

HPI

history

hx previous UTI no previous
similar symptoms to previous different symptoms

negatives/ROS

vitals

normal

genital exam

not necessary normal

abdomen

normal
+ CVA tenderness – + suprapubic tenderness –

urinalysis

+ hematuria – + leuks – + nitrites –

other

Assessment:

uncomplicated UTI complicated UTI pyelonephritis yeast infection bacterial vaginosis

details

Plan:

investigations

UA/UCx

antibiotics

empiric none - pending UCx based on previous Cx topical antifungals

follow-up

2-4 weeks PRN only

RTC

instructions given

other

URINARY/VAGINAL SYMPTOMS

S/

O/

A/

P/