ACUTE UNCOMPLICATED CYSTITIS IN
A 28-YEAR-OLD FEMALE: A
COMPREHENSIVE SOAP NOTE,
DIFFERENTIAL DIAGNOSIS, AND
EVIDENCE-BASED MANAGEMENT
(IHUMAN CASE STUDY: FAITH WARD)
I. Patient Encounter Summary
Patient: Faith Ward
Age: 28 years old
, Setting: Outpatient primary care clinic
Chief Complaint: "Burning when I pee" (Dysuria)
Faith Ward is a 28-year-old female presenting with a two-day history of acute dysuria,
urinary frequency, and urgency. She reports the symptoms began suddenly on Saturday
morning and have progressively worsened. She endorses significant discomfort,
describing a sharp, intense burning sensation localized to the urethra and suprapubic
area. The absence of systemic symptoms such as fever, chills, flank pain, nausea, or
vomiting is a critical component of the presentation, helping to rule out a more serious
upper urinary tract infection like pyelonephritis .
II. Comprehensive SOAP Note
SUBJECTIVE (S)
Chief Complaint (CC): "Burning and pain when I urinate."
History of Presenting Illness (HPI):
Faith is a 28-year-old female who presents with a chief complaint of dysuria that started
approximately two days ago. She describes the pain as a sharp, intense burning
sensation localized to her urethra and suprapubic area. She reports a significant increase
in urinary frequency, stating she feels the urge to urinate every 10-15 minutes. However,
when she attempts to void, only a small amount of urine is produced, and it is
accompanied by the sharp pain. She notes her urine appears cloudy, has a strong, foul
odor, and has developed a "slight pinkish tint." She denies any back or flank pain, fever,
chills, nausea, vomiting, or vaginal discharge. She states her appetite remains normal.
OLDCARTS Framework:
o Onset: Acute; started two days ago.
o Location: Suprapubic area and urethra.
o Duration: Continuous over the past two days.
o Character: Sharp, intense burning.
A 28-YEAR-OLD FEMALE: A
COMPREHENSIVE SOAP NOTE,
DIFFERENTIAL DIAGNOSIS, AND
EVIDENCE-BASED MANAGEMENT
(IHUMAN CASE STUDY: FAITH WARD)
I. Patient Encounter Summary
Patient: Faith Ward
Age: 28 years old
, Setting: Outpatient primary care clinic
Chief Complaint: "Burning when I pee" (Dysuria)
Faith Ward is a 28-year-old female presenting with a two-day history of acute dysuria,
urinary frequency, and urgency. She reports the symptoms began suddenly on Saturday
morning and have progressively worsened. She endorses significant discomfort,
describing a sharp, intense burning sensation localized to the urethra and suprapubic
area. The absence of systemic symptoms such as fever, chills, flank pain, nausea, or
vomiting is a critical component of the presentation, helping to rule out a more serious
upper urinary tract infection like pyelonephritis .
II. Comprehensive SOAP Note
SUBJECTIVE (S)
Chief Complaint (CC): "Burning and pain when I urinate."
History of Presenting Illness (HPI):
Faith is a 28-year-old female who presents with a chief complaint of dysuria that started
approximately two days ago. She describes the pain as a sharp, intense burning
sensation localized to her urethra and suprapubic area. She reports a significant increase
in urinary frequency, stating she feels the urge to urinate every 10-15 minutes. However,
when she attempts to void, only a small amount of urine is produced, and it is
accompanied by the sharp pain. She notes her urine appears cloudy, has a strong, foul
odor, and has developed a "slight pinkish tint." She denies any back or flank pain, fever,
chills, nausea, vomiting, or vaginal discharge. She states her appetite remains normal.
OLDCARTS Framework:
o Onset: Acute; started two days ago.
o Location: Suprapubic area and urethra.
o Duration: Continuous over the past two days.
o Character: Sharp, intense burning.
