GP Consultation Template

Summary

• 45yo F presented with a 3-day history of dysuria, frequency, and suprapubic pain; examination confirmed suprapubic tenderness and a positive urine dipstick for nitrites and leucocytes, with no signs of systemic infection or pyelonephritis. Diagnosed with an uncomplicated lower UTI and incidental stage 1 hypertension; commenced on a 3-day course of nitrofurantoin, advised on conservative fluid intake and analgesia, and requested to complete a 7-day home BP diary prior to a routine GP review.

• F2F

• seen alone

• Dysuria and urinary frequency

Consent

• Verbal consent obtained for AI scribe use during consultation.

History

• 3-day history of burning sensation on micturition and increased urinary frequency (passing small volumes every 1–2 hours).
• Patient attended for assessment of suspected urinary tract infection. Also discussed recent borderline high blood pressure readings noted on her home monitor over the past fortnight.
• Site: Suprapubic. Onset: Gradual, 3 days ago. Character: Dull ache with sharp burning on voiding. Radiation: Nil (no loin/flank pain). Associated symptoms: Nocturia (x3/night), malodorous cloudy urine. Timing: Constant dull ache, burning worse at termination of voiding. Exacerbating/Relieving: Partially relieved by paracetamol. Severity: 4/10.
• No visible haematuria, no fever, no rigors, no flank/loin pain, no nausea or vomiting, no vaginal discharge or irritation.
• Sexually active, recent honeymoon period, history of 1 previous UTI 2 years ago.
• PMH: / PSH: Mild asthma, laparoscopic appendicectomy (2015), borderline hypertension.
• DH: salbutamol (Ventolin®) 100 mcg INH PRN, paracetamol (Panadol®) 1,000 mg PO QID PRN.
• Allergies: Penicillin (maculopapular rash).
• FH: Father – T2DM and HTN; Mother – OA.
• SH: Lives with husband, works as a primary school teacher, non-smoker, alcohol 4–6 units/week, no recreational drugs, returned from Spain 1 week ago, independent (no carers).

Relevant Investigation Results

• Home BP readings brought by patient: average 144/92 mmHg over 5 days.
• Bloods (12/01/2026): HbA1c 36 mmol/mol, eGFR > 90 mL/min/1.73m², Total Cholesterol 4.8 mmol/L.
• CXR (10/11/2024): Normal heart size, clear lung fields, NAD.
• Urine dipstick: Blood +, Nitrites ++, Leucocytes +++, Protein trace, Glucose neg, Ketones neg.

Examination

• Alert, comfortable at rest, well hydrated, not clinically toxic.
• Temp 36.8 °C, Sats 99 %, HR 76 regular, BP 146/92 mmHg, RR 14
• HS I+II+0, capillary refill < 2 s, no peripheral oedema.
• Chest clear, good bilateral air entry, no wheeze or crepitations.
• Soft, mild suprapubic tenderness on palpation, no guarding or rebound, no renal angle tenderness bilaterally, bowel sounds normal.
• Normocephalic, atraumatic, no cervical lymphadenopathy, pharynx clear.
• Normal gait, full range of movement in lumbar spine, no paraspinal tenderness.
• Alert and orientated x3, gross neurology intact.
• Warm and well perfused, normal skin turgor, no rashes.

Diagnosis

1. Acute uncomplicated lower urinary tract infection (cystitis)
2. Stage 1 hypertension (uncoded, for confirmation via HBPM)
3. Pyelonephritis (excluded clinically), sexually transmitted infection (low risk, no discharge)

Plan

• Prescribed nitrofurantoin (Macrobid®) 100 mg MR PO BID for 3 days. Advised regular paracetamol 1,000 mg PO QID PRN for pain and to maintain oral fluid intake of 2–2.5 L/day.
• Routine F2F follow-up in 2 weeks with Practice Nurse to review 7-day home BP diary.
• Counselled on UTI prevention strategies (post-coital voiding, adequate hydration, wiping front to back). Provided instruction on correct home BP monitoring protocol (twice daily, morning and evening, two readings 1 minute apart for 7 days).
• Mid-stream urine (MSU) sent for MC&S. Fasting renal profile (U&Es) and ACR requested prior to nurse appointment.
• Advised to seek urgent medical review if symptoms fail to improve after 48–72 hours of antibiotics, or if developing fever, rigors, flank/back pain, frank haematuria, nausea/vomiting, or confusion.