Pyelonephritis Physical Exam Checklist Form
Document key findings from a pyelonephritis-focused physical examination using this checklist.
Examiner's Name
*
First Name
Last Name
Date of Examination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Temperature (°C)
*
Heart Rate (bpm)
General Appearance
Ill-appearing
Toxic
Well-appearing
Flank Tenderness
*
Left
Right
Bilateral
Absent
Costovertebral Angle (CVA) Tenderness
*
Left
Right
Bilateral
Absent
Abdominal Tenderness
*
Suprapubic
Diffuse
Absent
Urinary Symptoms Observed
*
Dysuria
Frequency
Urgency
Hematuria
None
Additional Notes
Submit Exam
Should be Empty: