Health History of a Female Patient with Urinary Tract Infection

Health History
Gender Female
Age 35
Current Medical History
What current medical conditions do you
have?
She is associated with urinary tract infection (UTI) with severe suprapubic pain and fever. She is
associated with reduced urine output and increased urgency.
Data related to his vital signs and other clinical symptoms was collected from his case reports: RR
24, Sats 93% on RA,
Circulation: HR 97 bpm,
BP 170/100 mmHg,
She described her pain as achy, burny and gripping. Her daytime frequency is 12-14 and nocturia is
3-4 voids.
Her urine is dark-colored.
Past Medical/Surgical History
What is you past medical/surgical history?
Medical History
T2DM, Ex-smoker (5 years before), HTN,
Hyperlipidaemia, chronic kidney disease stage
3 (Baseline eGFR 40 ml/min/1.73m2), chronic
venous leg ulcer to L) leg, anxiety. No known
declared allergies (NKDA). She is obese
(BMI 30) and drinks 1 bottle of wine every
night. She mentioned that previously she
visited two urologists and two gynaecologists.
Surgical History
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She is using antimuscarinics, trimethoprim-
sulfamethoxazole, tricyclic antidepressants
and oxycodone. She reported chills and
feverShe has had 2 prior UTIs in the past year,
which were successfully treated each time
with trimethoprim-sulfamethoxazole (TMP-
SMX) 160 mg/800 mg twice a day for 3 days.
The last UTI was 4 months ago which was
associated with pyelonephritis.
Medications
What medications do you take?
List medications and dosages (where possible)
She is administered with medications such as paracetamol (650 mg), oxycodone (20 mg extended
release tablets per day), metformin (500 mg every 12 hours) and captopril (25 mg PO q 8-12 hr).
Do you live alone/with someone? With someone
Are you able to care for yourself?
Do you need help with showering?
Do you need help with toileting?
Do you need help with dressing?
Yes
No
No
No
Do you have a vision impairment?
Do you wear glasses?
What type of glasses are they?
Yes
No
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Do you have a hearing impairment?
Do you wear a hearing aid?
Which ear do you wear them in?
No
No
Do you wear dentures?
Are they upper/bottom dentures?
No
Do you drink alcohol?
How often do you drink?
How many drinks do you have each day?
Yes
1 bottle per night
Do you smoke?
How many cigarettes do you smoke a day?
Ex-smoker
Do you follow a special diet?
What is the special diet?
What is your height?
What is your weight?
Yes
Diabetic diet
150 cm
75 kg
Do you have any mobility issues?
Do you use a mobility aid?
What mobility aid do you use?
Do you do any exercise?
No
No
Do you have any wounds?
Where are they?
Yes
1) Nursing assessment tool used – Result – Physical and vital sings were performed for Ms. ABC. Different procedures were
performed to carry out physical assessment such as observation, auscultation, percussion and
palpation. Physical assessment reported that her skin, face, eyes, chest, abdomen, elbows and joints
were normal. Lymph nodes, chest wall and abdomen were normal; however, lumps were observed in
the leg region. Lub-dub sound was observed in heart and murmurs were observed in the heart sound.
Lungs produced normal sounds; however, abdomen produced abnormal bowel sound. Observed vital
sings were RR 24 bpm, HR 97 bpm, Temp 38.6̊ and BP 170/90 mmHg. Moreover, bilateral pitting
oedema was observed on her calves. During neurological observation, lack of coordination was
observed (Lambe, Currey, and Considine, 2017).
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2) Nursing assessment tool used – Result – Pain assessment in Ms. ABC was performed using PQRST algorithm. Pain assessment is
important aspect in her because it is one of the most important symptoms of UTI. Moreover, pain
assessment is also useful in the selecting appropriate medications for the pain management. Pain
assessment was performed by asking questions such as P = Provocation/Palliation, Q =
Quality/Quantity, R = Region/Radiation, S = Severity Scale and T = Timing. Pain assessment was
performed at different time points of the day to obtain valid data because pain assessment is a
subjective method. Hence, based on the physical and psychological status of the patient, pain
assessment might vary. However, pain assessment data was consistent at different time points of the
day. Reported pain in Ms. ABC was 7 on 0 – 10 scale. Hence, should be considered as severe pain
(Varndell, Fry, and Elliott, 2017).
3) Any other nursing assessment tools used
-
Result –
Any other information you wish to add in relation to the person you interviewed.
Assessment 1 – Case Study Template
1) Consider the Individual (25 words)
Ms. ABC (35) years will be considered for care who is associated with Urinary Tract Infection (UTI).
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