Student Name:
Course:
Today’s date: 7
======================================================================================
Demographics: J. M, 36 YO Female, She/Her
Visit Date:
Clinical Location:
SUBJECTIVE:
Chief Complaint: “Every time I pee, it burns really bad and I feel like I have to go constantly.”
Source & Reliability of History: Patient is the primary historian and provides clear, consistent information.
HPI: S.M. is a 36-year-old female presenting with three days of burning with urination, urinary urgency, and frequency.
Onset: 3 days ago, symptoms began suddenly and have worsened each day.
Location: lower abdominal pressure
Duration:4 days now
Characteristics: Pain described as “sharp and burning”, rated 6/10 on the pain scale.
Aggravating: Denies any specifics triggers that make it worse.
Relieving: Denies any relief.
Treatments attempted: 1 dose of ibuprofen 400mg by mouth yesterday without relief. Denies any other OTC
treatments.
Any additional narrative:
She denies flank pain. Reports lower abdominal pressure only.
Denies having fever, chills, vomiting, nausea, vaginal itching, vaginal discharge, new sexual partners, and
hematuria.
No recent antibiotic use.
Last menstrual period was 6/30/2026. No chance of pregnancy per the patient.
Denies a history of kidney stones.
Dinks about 40oz of water daily. She admits to increased caffeine intake.
, Denies having used any new detergents, soaps, or hygiene products.
No prior diagnosis of UTI in the past 2 years. No known sick contacts. No recent travel. No trauma to the pelvic
area.
PMH:
Anxiety disorder (diagnosed 2015)
Seasonal allergies (diagnosed 2010)
GERD (diagnosed 2018)
UTI (last occurrence 2022)
PSH: (Surgical history)
Cesarean Section (2016)
Tonsillectomy (1999)
Family History
Mother: living (62 years old), type 2 diabetes, hypertension
Father: living (64 years old), hyperlipidemia
Sister: Living (33 years old), No medical conditions
Maternal Grandmother: Deceased (78 years old) from breast cancer
Maternal Grandfather: Deceased (81 years old) from coronary artery disease
Paternal Grandmother: Deceased (85 years old) from MI, also had osteoarthritis
Paternal Grandfather: Deceased (79 years old) from stroke, heart disease
Social determinants of health:
J. M. is married with one child. She resides in a 2-story home located in Kentucky. She is a high school English teacher
and has been for the past 10 years at a local public high-school. She reports a well-balanced omnivorous diet. She
consumes iced coffee daily, about 2 cups. She denies drinking energy drinks. She does drink zero sugar sodas. She
exercises 3-4 times a week doing barre and Pilates at a local studio. She states she has never smoked tobacco or used illicit
drugs. She does socially drink wine about 1-2 glasses 2 times a week. She denies any environmental exposure safety
concerns and feels safe at home.
PHQ-9: N/A
Vaccinations/Immunizations:
Course:
Today’s date: 7
======================================================================================
Demographics: J. M, 36 YO Female, She/Her
Visit Date:
Clinical Location:
SUBJECTIVE:
Chief Complaint: “Every time I pee, it burns really bad and I feel like I have to go constantly.”
Source & Reliability of History: Patient is the primary historian and provides clear, consistent information.
HPI: S.M. is a 36-year-old female presenting with three days of burning with urination, urinary urgency, and frequency.
Onset: 3 days ago, symptoms began suddenly and have worsened each day.
Location: lower abdominal pressure
Duration:4 days now
Characteristics: Pain described as “sharp and burning”, rated 6/10 on the pain scale.
Aggravating: Denies any specifics triggers that make it worse.
Relieving: Denies any relief.
Treatments attempted: 1 dose of ibuprofen 400mg by mouth yesterday without relief. Denies any other OTC
treatments.
Any additional narrative:
She denies flank pain. Reports lower abdominal pressure only.
Denies having fever, chills, vomiting, nausea, vaginal itching, vaginal discharge, new sexual partners, and
hematuria.
No recent antibiotic use.
Last menstrual period was 6/30/2026. No chance of pregnancy per the patient.
Denies a history of kidney stones.
Dinks about 40oz of water daily. She admits to increased caffeine intake.
, Denies having used any new detergents, soaps, or hygiene products.
No prior diagnosis of UTI in the past 2 years. No known sick contacts. No recent travel. No trauma to the pelvic
area.
PMH:
Anxiety disorder (diagnosed 2015)
Seasonal allergies (diagnosed 2010)
GERD (diagnosed 2018)
UTI (last occurrence 2022)
PSH: (Surgical history)
Cesarean Section (2016)
Tonsillectomy (1999)
Family History
Mother: living (62 years old), type 2 diabetes, hypertension
Father: living (64 years old), hyperlipidemia
Sister: Living (33 years old), No medical conditions
Maternal Grandmother: Deceased (78 years old) from breast cancer
Maternal Grandfather: Deceased (81 years old) from coronary artery disease
Paternal Grandmother: Deceased (85 years old) from MI, also had osteoarthritis
Paternal Grandfather: Deceased (79 years old) from stroke, heart disease
Social determinants of health:
J. M. is married with one child. She resides in a 2-story home located in Kentucky. She is a high school English teacher
and has been for the past 10 years at a local public high-school. She reports a well-balanced omnivorous diet. She
consumes iced coffee daily, about 2 cups. She denies drinking energy drinks. She does drink zero sugar sodas. She
exercises 3-4 times a week doing barre and Pilates at a local studio. She states she has never smoked tobacco or used illicit
drugs. She does socially drink wine about 1-2 glasses 2 times a week. She denies any environmental exposure safety
concerns and feels safe at home.
PHQ-9: N/A
Vaccinations/Immunizations:
