SUBJECTIVE: The patient is a (XX)-year-old female patient of Dr. John Doe here complaining of continued urinary frequency. She was treated last week with an antibiotic for a bladder infection. Urinalysis at that time was over a 100,000 E. coli. On the (xx)th, the patient began ciprofloxacin 250 mg b.i.d. x7 days. Her last dose was today. On the (xx)st, the patient saw another provider and urinalysis was collected showing 50 to 100,000 of mixed bacteria, likely contamination.
She is followed by Dr. Jane Doe in urology who has her on Detrol LA 2 mg. She has other medications; Prilosec 20, vitamin C, Vicodin 5/500, and levothyroxine 25 mcg.
The patient denies any discrete burning with the urine. No fevers, no chills. No back pain. It is urinary frequency that is her prime concern and she knows that Dr. Jane Doe had thought she could improve these symptoms by going to the 4 mg dose of Detrol LA from prior conversation.
OBJECTIVE: The patient’s vital signs revealed a blood pressure of 124/82, heart rate of 78, weight of 178, and temperature of 98.4. She appears comfortable, nonseptic, in no acute distress. Lung sounds are clear. Heart has regular rate and rhythm.
LABORATORY DATA: Urinalysis shows trace blood, moderate protein, and small leukocytes. There are no nitrites.
ASSESSMENT: Status post urinary tract infection with urinary frequency.
PLAN: Recommend sending today’s urinalysis for culture. She can try Pyridium, which may help with her symptoms now. It is most important that she get back on her diuretic, which she has stopped, and a consideration to take this in the very early morning hours if she gets up to void would be appropriate so she can go back to sleep.
We will discuss this in two days’ time to see if the urine has completely cleared. At that time, if this is a negative urinalysis, C&S, then we would increase the Detrol LA to 4 mg per day. The patient will call back with other questions.
