Concise Consultation Summary and Patient Message

Consult Summary

42yo F p/w 3/7 hx dysuria & urinary frequency, denies fever/flank pain/vaginal d/c; O/E afebrile (36.8 °C), HR 76 bpm, BP 118/74 mmHg, mild suprapubic tenderness, no CVA tenderness, urine dip +leukocytes/+nitrites, dx uncomplicated cystitis, Rx nitrofurantoin (Macrobid®) 100 mg PO BID x 5/7, advised PO fluids & return if Sx worsen.

Patient Message

Kia ora Sarah,

Thank you for coming in to see me today. As we discussed, your symptoms and urine test show a straightforward bladder infection, which should start feeling much better within a couple of days of starting treatment.

Next Steps:

• Take your antibiotic, nitrofurantoin (Macrobid®), 100 mg by mouth twice daily (morning and night with food) for 5 days. Please finish the whole course even if you feel better sooner.
• Drink plenty of water over the next few days to help flush out your bladder.
• You can take paracetamol (Panadol®) 1,000 mg by mouth up to four times a day if you need relief from the stinging or tummy discomfort.

What to Watch Out For (Red Flags): Please seek medical care straight away if you develop any of the following symptoms, as they can mean the infection is spreading to your kidneys:

• High fever, chills, or shakes
• New pain in your lower back or side (below your ribs)
• Feeling sick (nausea) or vomiting
• Seeing visible blood in your urine

Follow-Up: If your symptoms completely clear up after finishing the antibiotics, you do not need another appointment. However, if you are not feeling noticeably better after 3 days of treatment, or if your symptoms get worse at any point, please call the clinic on (09) 555-0142 to book a follow-up visit (or call Healthline on 0800 611 116 after hours).

Ngā mihi, Dr. Aroha Patel