Date:
Patient:
(Chief Complaint): Briefly describe the patient’s main reason for presentation, typically urinary frequency, urgency, dysuria (painful urination), and sometimes hematuria (blood in the urine).
History of Present Illness:
Onset and duration of symptoms
Frequency and urgency of urination
Character of pain (burning, stinging)
Amount of urine voided (small amounts frequently)
Presence of hematuria (gross or microscopic)
Dyspareunia (painful intercourse)
Past medical history (urinary tract infections (UTIs), sexually transmitted infections (STIs), bladder stones, anatomical abnormalities)
Medications (current medications, recent antibiotics)
Sexual history (number of partners, use of contraception)
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate)
General examination (appearance of illness)
Abdominal examination (costovertebral angle tenderness – uncommon in uncomplicated cystitis)
Genital examination (normal or mild vulvar erythema in females)
Laboratory Findings:
Urinalysis:
Pyuria (white blood cells in the urine) is suggestive of infection.
Hematuria (red blood cells in the urine) may be present.
Nitrates may be positive (less specific than pyuria).
Urine culture and sensitivity:
Ordered to identify the causative organism and guide antibiotic selection.
Assessment:
Summarize the findings and diagnose acute cystitis based on clinical presentation and urinalysis.
Consider the possibility of complications (e.g., pyelonephritis) if fever or flank pain is present.
Plan:
Oral Antibiotics: Select an antibiotic based on local resistance patterns and patient allergies. Common choices include nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or a fluoroquinolone.
Symptomatic Relief:
Increased fluid intake (water preferred)
Pain relievers (phenazopyridine) – use with caution due to potential side effects
Urinalysis follow-up: Consider repeating urinalysis in 1-2 weeks to ensure resolution of infection.
Progress Notes:
Document daily assessments including frequency and urgency of urination, pain level, and any new symptoms.
Note any laboratory results obtained during the hospitalization or clinic visit.
Discharge Instructions:
Complete the prescribed antibiotic course.
Increase fluid intake to dilute urine and promote urination.
Consider cranberry products (limited evidence for efficacy).
Practice good hygiene habits (wiping front to back, voiding after intercourse).
Schedule a follow-up appointment to discuss urinalysis results and address any further concerns.
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment.