Cc: “I think I might have a UTI”
54 y/o female with PMHx of Diabetes, HTN, and High Cholesterol presents to the urgent care with complaints of dysuria and urinary frequency x 5 days. She states that a day prior to the onset of her symptoms she was starting treatment with erythromycin for a sinus infection. She states the very next day she began to experience a burning sensation with urination, and urinary frequency. She states that she has been experiencing feelings of incomplete voiding and fullness after urination.
For my ambulatory care evaluation, I met with my site evaluator on two different occasions to present my patient cases. For my second site evaluation, I presented the case above which is of a patient that came in with a potential urinary tract infection. The full H&P is also included as an attachment for full reference. I also based my journal article on this patient and the use of cranberry juice/ extracts as an adjunct in treating and preventing UTIs. During the evaluation, my preceptor and I went over each section of my H&P from the HPI to the assessment and plan. For this presentation, I did not receive negative feedback, but I did receive feedback on careful wording of remarks in my H&Ps. During my evaluation of this patient, I could not perform a pelvic exam as the patient declined it, but I noted this in my assessment section as “Overall exam is normal with the exception of the genitourinary exam”. My preceptor encouraged me to be careful when wording things and said to try to note that the exam itself was declined by the patient and not neglected on my part as a provider. Otherwise, my feedback from my preceptor was positive. My evaluation for this rotation was with an evaluator I had much earlier on at the beginning of my rotations (my 2nd rotation to be exact.) This was my 8th rotation (out of 9) so I was encouraged to see that my evaluator affirmed that I have improved in my history eliciting skills, H&Ps, and my assessment and plans over the past months. Moving forward to my next and last rotation I hope to continue to challenge myself to grow and improve my skills and knowledge.