Focused Exam UTI with Antibiotic Sensitivity Shadow Health Assessment

Subjective Data Collection: 25 of 26 (96.2%)

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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

Found:

Indicates an item that you found.

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Indicates an item that is available to be found.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Chief Complaint

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Established chief complaint

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(Found)

Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

Example Question:

How is your urination?

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History of Present Illness

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Asked about onset and duration of symptoms

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(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

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Asked about additional symptoms of UTI

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Asked about aggravating factors of pain

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Reports urination makes the pain worse

(Available)

Example Question:

Does urination make the pain worse?

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Asked about severity of pain

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Reports pain on urination as 7/10

(Available)

Example Question:

On a scale from one to ten, how bad is the pain?

Past Medical History

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Asked about relevant past medical history

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Reports no existing relevant health conditions

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

Do you have any health issues?

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Asked about general allergies

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Home Medications

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Asked about home medications

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(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

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Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

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(Available)

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How often do you take birth control?

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Reports 28-pill pack

(Found)

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Reports no adverse effects

(Found)

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Reports unsure of dosage

(Found)

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Asked about medication allergies

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(Found)

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Followed up on reaction to penicillin

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(Found)

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Reports nausea and vomiting

(Found)

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Social History

Finding:

Asked about substance use

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(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

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Followed up on alcohol use

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How many drinks do you have a week?

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Asked about sexual activity

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Family Medical History

Finding:

Asked about relevant family medical history

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Reports father is healthy

(Found)

Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.

Example Question:

How is your father’s health?

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(Found)

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(Available)

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Review of Systems

Finding:

Asked about general symptoms

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(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Focused Exam UTI with Antibiotic Sensitivity Shadow Health Assessment

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Asked about review of systems for gastrointestinal

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Comments

Education & Empathy : 5 of 6 (83.3%)

During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.

Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient

DEBRIEF

Assessment

The patient suffers from UTI

Model Note

Makayla Henderson is a 21-year-old Biracial woman presenting with an uncomplicated UTI. She is a senior college student. Her UTI symptoms began three days ago, and she has experienced pain during urination, a burning sensation, and increased urgency to urinate. She is also experiencing some cramping in her lower abdominal region

Model Note

I prescribed Ms. Henderson a course of …

Medication Selection Score: 18 out of 18 points

This activity represents how well you were able to synthesize subjective data, objective data, guidelines, interactions, and contraindications to select the most effective medications(s) for the patient’s problems

	First Try	Second Try	Third Try
Totals
Combined total points	18 out of 18 points
Total points per column	+ 18 points

Urinary Tract Infection
Medication(s) Selected	nitrofurantoin
Points Earned	✓ + 9 points	✓	✓
Rationale	Congratulations! Nitrofurantoin is the best choice for this scenario. In areas with an antibiotic resistance to a sulfamethoxazole / trimethoprim combination drug, nitrofurantoin is the best first line of defense antibiotic for an uncomplicated UTI. This drug would also not contraindicate with Ms. Henderson’s penicillin hypersensitivity.

Urination Pain and Increased Frequency
Medication(s) Selected	phenazopyridine
Points Earned	✓ + 9 points	✓	✓
Rationale	Congratulations! As a non-opioid analgesic, phenazopyridine is the best choice to provide relief from urinary tract symptoms such as pain, burning, and frequency.

Patient Teaching Score: 9.5 out of 11

Topics priorized for patient teaching

Education Items

Greet the patient and explain why you need to educate them

Greet the patient and explain why you need to educate them

	Hi, I need to educate you the need to understand the medication process and dosage.	Statement 8/7/2020 2:03:21 PM
	Hey, sure thing. [AUDIO COMING SOON]

Model Statement: Hi, Makayla. We’re going to be going over how to safely take your medication.

XYZ

Model Plan

(1 point) Take the full course of antibiotics
(1 point) Take with meals for absorption
(1 point) Take missed doses as soon as possible
(1 point) Drink noncaffeinated liquids

Topics priorized for patient teaching

Education Items

(1 point) Take the full course of antibiotics
(1 point) Take at the same time daily
(1 point) Take missed doses as soon as possible
(1 point) Adverse effects include GI upset

Take the full course of antibiotics

	Take the full course of antibiotics	Statement 8/7/2020 2:03:56 PM
	Ok – but what if I start feeling better?
	You continue taking it until you finish the dose	Statement 8/7/2020 2:04:29 PM
	Oh, ok. That makes sense.

Model Statement: It’s important to finish a full course of antibiotics, even if you start to feel better. Antibiotic resistance can happen if a bacteria is exposed enough times to an antibiotic, but is not completely killed; this means that the stronger, resistant bacteria are able to adapt. Finishing a full course of antibiotics decreases the risk of antibiotic resistance, which helps everyone.

Take at the same time daily

	Take at the same time daily	Statement 8/7/2020 2:04:55 PM
	Oh, ok.

Model Statement: Taking antibiotics at the same time every day ensures that the medication is in your system for the same amount of time, which makes it the most effective.

Take missed doses as soon as possible

	Take as soon as possible to maintain the therapeutic effect of the drug.	Statement 8/7/2020 2:05:50 PM
	I definitely don’t want that to happen. Thanks.

Model Statement: If you miss a dose of your antibiotics, take your dose as soon as you remember, and then take your next dose at its regularly scheduled time.

Adverse effects include GI upset

	The medication has adverse effect which may include causing pain in your stomach	Statement 8/7/2020 2:06:29 PM
	Ew. Thanks for telling me.

Model Statement: Sometimes people experience gastrointestinal issues when they take antibiotics. Some find it helpful to take probiotic supplements to help the “good” bacteria in your system.

Model Plan

(1 point) Take as needed to relieve pain
(1 point) Take with meals to avoid GI upset
(1 point) Continue taking antibiotics while on this drug
(1 point) Bodily fluids may appear orange

Topics priorized for patient teaching

Education Items

(1 point) Take with meals to avoid GI upset
(0.5 points) Contact provider if you experience signs of an allergic reaction rash
(1 point) Bodily fluids may appear orange
(0.5 points) Contact provider if you experience signs of liver problems

Take with meals to avoid GI upset

	Take with meals to ensure that the GI upset is minimized	Statement 8/7/2020 2:06:55 PM
	Ok. Sounds like a good plan.

Model Statement:

Contact provider if you experience signs of an allergic reaction rash

		Statement 8/7/2020 2:09:25 PM
	Got it.

Bodily fluids may appear orange

	.	Statement 8/7/2020 2:07:53 PM
	Weird! Thanks for letting me know.

Model Statement:

Contact provider if you experience signs of liver problems

		Statement 8/7/2020 2:10:32 PM
	Oh, ok. Will do.

Model Statement:

Model Plan

(1 point) Wear loose-fitting, cotton underwear
(1 point) Wipe front to back when you use the restroom
(1 point) Return if you do not improve

Topics priorized for patient teaching

Education Items

(1 point) Urinate before and after sexual intercourse
(0.5 points) Do not rely on cranberry pills or juice to treat UTIs
(1 point) Wipe front to back when you use the restroom

Urinate before and after sexual intercourse

	Urinating before and after sexual contact will clear the urethra.	Statement 8/7/2020 2:11:18 PM
	Oh, I didn’t know. I’ll be sure to do that. [AUDIO COMING SOON]

Model Statement:

Do not rely on cranberry pills or juice to treat UTIs

	Use medications to treat UTIs..	Statement 8/7/2020 2:11:43 PM
	I figured it couldn’t hurt, but I’ll definitely take the medicine you give me. [AUDIO COMING SOON]

Model Statement:

Wipe front to back when you use the restroom

	Wiping front and back will clean the discharges	Statement 8/7/2020 2:12:17 PM
	Oookay. Gotcha. [AUDIO COMING SOON]

Model Statement:

Topics priorized for patient teaching

Education Items

Educate the patient on anything else and say goodbye. Focused Exam UTI with Antibiotic Sensitivity Shadow Health Assessment

Educate the patient on anything else and say goodbye

	Always use condoms when you want to engage in sex. Good bye.	Statement 8/7/2020 2:12:59 PM
	Ok. See you later.

Model Statement: Make sure to follow all of the instructions we discussed. Have a nice day.

Prescription Writing Score: 20 out of 20

Patient Information: 1 out of 1 point
This section covers the information identifying the patient. Any incorrect answers here could result in the pharmacist not dispensing the medication to the patient, and therefore you will lose the point for this section.
Field	Student’s Answer	Is Correct?	Feedback
Patient Name	Makayla Henderson	✓
Date of Birth	06/20/1999	✓

Safe and Effective Dosage: 7 out of 7 point
This section measures how well you put together a safe and effective dose for the patient’s problems. Any incorrect answers here could lead to under or overdosing the patient, and therefore you will lose all of the points in this section.
Field	Student’s Answer	Is Correct?	Feedback
Medication Name		✓
Dosage	1 (one) tablet	✓
Strength	100 mg extended release	✓
Frequency	every 12 (twelve) hours	✓
Duration	5 (five) days	✓

Additional Fields: 1 out of 1 point
This section covers the rest of the remaining fields for an accurate prescription. Any incorrect answers here could lead to a legally invalid prescription, and therefore you will lose the point for this sections.
Field	Student’s Answer	Is Correct?	Feedback
Route	mouth	✓
Quantity	10 (ten) tablets	✓
Refills	0	✓
Indication	Urinary Tract Infection	✓

Additional Information
This section covers the additional information and generic substitution fields for the prescription. These are not graded by Shadow Health, but your instructor may choose to do so when inputting your grade.
Field	Student’s Answer
Dispense As Written?	Required
Additional Information	Kindly inform us of any adverse events,..

Signature and Date: 1 out of 1 point
This section covers the information identifying who wrote the prescription and when. Any errors in this section could result in the pharmacist not dispensing the medication to the patient, and therefore you will lose the point for this section.
Field	Student’s Answer	Is Correct?	Feedback
Signature	Dr.	✓
Date	07/08/2020	✓

Patient Information: 1 out of 1 point
This section covers the information identifying the patient. Any incorrect answers here could result in the pharmacist not dispensing the medication to the patient, and therefore you will lose the point for this section.
Field	Student’s Answer	Is Correct?	Feedback
Patient Name	Makayla Henderson	✓
Date of Birth	06/20/1999	✓

Safe and Effective Dosage: 7 out of 7 point
This section measures how well you put together a safe and effective dose for the patient’s problems. Any incorrect answers here could lead to under or overdosing the patient, and therefore you will lose all of the points in this section.
Field	Student’s Answer	Is Correct?	Feedback
Medication Name		✓
Dosage	1 (one) tablet	✓
Strength	200 mg	✓
Frequency	3 (three) times daily	✓
Duration	2 (two) days	✓

Additional Fields: 1 out of 1 point
This section covers the rest of the remaining fields for an accurate prescription. Any incorrect answers here could lead to a legally invalid prescription, and therefore you will lose the point for this sections.
Field	Student’s Answer	Is Correct?	Feedback
Route	mouth	✓
Quantity	6 (six) tablets	✓
Refills	0	✓
Indication	UTI Pain	✓

Additional Information
This section covers the additional information and generic substitution fields for the prescription. These are not graded by Shadow Health, but your instructor may choose to do so when inputting your grade.
Field	Student’s Answer
Dispense As Written?	Required
Additional Information	Alert you provider when adverse events occur. Be sure to complete the dosage.

Signature and Date: 1 out of 1 point
This section covers the information identifying who wrote the prescription and when. Any errors in this section could result in the pharmacist not dispensing the medication to the patient, and therefore you will lose the point for this section.
Field	Student’s Answer	Is Correct?	Feedback
Signature	Dr.	✓
Date	07/08/2020	✓