Assignment - Shadow Health Focused - UTI with Antibiotic Sensitivity

Assignment 5.2: Shadow health focused exam: UTI with antibiotic sensitivity 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 university 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 external orifice of the urethra accompanied by cramping in the lower abdomen. Denies and any fatigue, fever or holding urine for long periods of time. When questioned about her sexual history, she states she had sex 4 days ago and had a single partner for a period of time now. Patient also states she has a positive view of her body and a sex-positive attitude. States she belongs to a club on campus. Last menstrual cycle ended 2 weeks ago. States she is very good about taking her birth control and monitors it via the 28 pill click pack. History: Denies any relevant existing medical history. Denies history of urinary tract infection. Social history: Drinks alcohol about 2 nights a week, 2-3 drinks per week. States it is infrequent and school is the priority. Denies any substance abuse. Family history: No medical history on paternal side. On the maternal side, mother is a breast cancer survivor. Grandmother passed of breast cancer. Prescriptions: Adilson Kiefer 09/29/2019 Patient: Makayla Henderson DOB: 06/20/1998 Allergy: Penicillin Nitrofurantoin 100mg extended release. Take 1 (one) tablet by mouth every 12 (twelve) hours for 5 (five) days. Dispense 10 (ten) tablets; no refills. Please take with meals. Indication: Urinary Tract infection. Phenazopyridine 200mg. Take 1(one) tablet by mouth 3 (three) times a day for 2 (two) days. Dispense 6 (six) tablets; no refills. Please take with meals. Indication: Urinary Tract Infection pain. Patient education: Ms. Henderson was instructed to take the full course of antibiotics even she starts feeling better and to take it with meals for absorption. Adverse effects include GI upset. She was also instructed to contact provider if you experience signs of an allergic reaction such as a rash. In regards to the Phenazopyridine, Ms. Henderson was instructed to continue taking antibiotics while on this drug as this is only an analgesic for pain. She is aware that bodily fluids may appear orange and that this is temporary. She should increase her water intake and urine output to help clear urinary tract infection faster. Patient has been instructed to contact provider if she experiences signs of an allergic reaction or rash. What did you learn? Shadow health is a software that makes you think and yet gives you the flexibility to able to ask questions freely without any judgement. It is interesting because it allowed to me to explore the treatment of UTI in an outpatient female which is not my typical nursing practice. I was able to learn about antibiotics and clear up some differences that I did not know such as the use of certain drugs in certain types of patients. I wanted to make sure I touched upon all the subjects needed to teach the patient how to properly manage an urinary tract infection and it allowed me to expand my knowledge on how to manage pain and discomfort due to the infection. Overall, I was able to learn UTI management, get a little taste of what a nurse practitioner does and start mentally preparing for what is to come.