iHuman Case Study: Brianna Gill — 28-Year-Old Female with Dysuria & Acute Cystitis SOAP Note

Brianna Gill – v v




"Pain When I Pee": Full History & Phy
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sical Encounter | Chamberlain,
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NR602
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BRIANNA GILL – Comprehensive i-Human Case Study
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NR602 Primary Care of the Childbearing and Childrearing Family
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, I. PATIENT INFORMATION

Field Details
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Name Brianna Gill v




Age 28 yearsv




Sex Female

Ethnicity Caucasian

Height 5' 2" (157 cm)
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Weight 132.0 lb (60.0 kg)
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BMI 24.1 (Normal)
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Setting Outpatient Primary Care Clinic
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Source Patient




II. CHIEF COMPLAINT (CC)

"It hurts when I pee"

Patient reports dysuria (painful urination), urinary frequency, and suprapubic
discomfort. She describes her urine as cloudy and malodorous .




III. HISTORY OF PRESENTING ILLNESS (HPI) – OLD-CARTS Format


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, Component Details

Onset Began approximately 48 hours ago; gradual onset with increasing intensi
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Location
Burning sensation at urethral opening during urination; dull, aching
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pain in suprapubic/pelvic area (deep in pelvis)
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Duration
Sharp pain lasts throughout voiding; dull pelvic ache is constant mo
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st of time
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Character Sharp, burning sensation during urination (classic dysuria)
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Aggravating
Urination triggers sharp pain; movement worsens pelvic pressure
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Factors
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Relieving Heating pad on abdomen provides mild relief for pelvic ache; ibuprofen p
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Factors
v rovided minimal relief
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Timing Symptoms are consistent throughout the day; occurs every time she voi
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Severity 7/10 pain during voiding; lower intensity for dull ache
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Associated Symptoms v




 Urinary frequency – feels the urge to void every 30 minutes
 Urgency – strong, sudden need to urinate
 Cloudy, malodorous urine
 Suprapubic pressure/pain
 No gross hematuria (no visible blood in urine)


Pertinent Negatives
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, System Negative Finding v




Genitourinary No vaginal discharge, no itching
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Genitourinary No visible blood in urine
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Gastrointestinal No nausea, vomiting, or diarrhea
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Systemic No fever, chills, or night sweats
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Renal No flank pain (rules out pyelonephritis)
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IV. REVIEW OF SYSTEMS (ROS)

System Findings

General No weight changes, no fatigue, overall feels normal
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Integumentary No new rashes or skin changes
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HEENT No headaches, no vision changes
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Respiratory No shortness of breath or cough
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Cardiovascular No chest pain or palpitations
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Gastrointestinal

Suprapubic pressure only (no nausea/vomiting) Genitou
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rinary

Dysuria, frequency, urgency; cloudy/malodorous urine
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Musculoskeletal No joint pain or muscle aches
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Neurological No headaches, dizziness, or paresthesias
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