Senior Review post-Junior discussion
Created by
Abid Nisar
Specialty
Emergency Medicine Specialist
Last edited
12/21/2025
Uses
3 times
Tags
About this template
Used when a junior doctor presents a case to a senior, who then records the discussion and formulates a management plan for the patient.
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Senior Review (As per Discussion) Time Stamp: 2024/06/20 15:35 (UTC+0)
Case Summary: 45-year-old female with a 2-day history of lower abdominal pain and dysuria. No fever, nausea, or vomiting. Past medical history includes hypertension. On examination: lower abdominal tenderness, no guarding or rebound. Urinalysis shows positive leukocytes and nitrites.
Discussion Points:
- Differential includes urinary tract infection (UTI), pelvic inflammatory disease, or renal colic.
- Consideration of underlying risk factors given past hypertension.
- No features of systemic infection or sepsis.
Senior Assessment: Presentation consistent with uncomplicated lower urinary tract infection. No red-flag features presently. Stable observations and examination.
Plan:
- Commence nitrofurantoin 100 mg PO BID for 5 days.
- Advise patient to increase oral fluid intake.
- Safety net: return if worsening pain, fever, vomiting, or signs of systemic infection.
- Follow-up in 48-72 hours or sooner if no improvement.
- GP review for blood pressure management discussed.
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