Comprehensive Clinical Case Study: Acute
Uncomplicated Cystitis (N30.00) in a 28-Year-Old
Female – A Comprehensive Clinical Guide for Pain
Assessment, Diagnosis, and Management of Acute
Cystitis with Complete SOAP Note, Follow-Up Plan,
and Clinical Dialogue
, COMPREHENSIVE CASE STUDY
Patient Demographics
• Name: Faith Ward
• Age: 28 years
• Gender: Female
• Chief Complaint: "It hurts when I urinate"
FULL DIALOGUE: Pain Assessment
Initial Encounter
Provider: "Good morning, Faith. I understand you're having some discomfort.
Can you tell me what brought you in today?"
Patient: "It really hurts when I pee. It started a couple of days ago and it's
getting worse."
Provider: "I'm sorry to hear that. Can you describe the pain for me?"
Patient: "It's like a burning, stinging feeling whenever I go to the bathroom.
And even when I'm not peeing, I have this dull ache down low in my belly."
Provider: "On a scale of 0 to 10, with 0 being no pain and 10 being the worst
pain you've ever experienced, how would you rate this pain?"
Patient: "When I'm actually urinating, it's probably a 7 or 8. The ache in my
belly is more like a 4 or 5."
Provider: "How long does the burning sensation last?"
Patient: "It's mostly just when I'm passing urine, but sometimes I feel a little
uncomfortable for a few minutes after."
Provider: "Have you noticed you need to urinate more often than usual?"
Uncomplicated Cystitis (N30.00) in a 28-Year-Old
Female – A Comprehensive Clinical Guide for Pain
Assessment, Diagnosis, and Management of Acute
Cystitis with Complete SOAP Note, Follow-Up Plan,
and Clinical Dialogue
, COMPREHENSIVE CASE STUDY
Patient Demographics
• Name: Faith Ward
• Age: 28 years
• Gender: Female
• Chief Complaint: "It hurts when I urinate"
FULL DIALOGUE: Pain Assessment
Initial Encounter
Provider: "Good morning, Faith. I understand you're having some discomfort.
Can you tell me what brought you in today?"
Patient: "It really hurts when I pee. It started a couple of days ago and it's
getting worse."
Provider: "I'm sorry to hear that. Can you describe the pain for me?"
Patient: "It's like a burning, stinging feeling whenever I go to the bathroom.
And even when I'm not peeing, I have this dull ache down low in my belly."
Provider: "On a scale of 0 to 10, with 0 being no pain and 10 being the worst
pain you've ever experienced, how would you rate this pain?"
Patient: "When I'm actually urinating, it's probably a 7 or 8. The ache in my
belly is more like a 4 or 5."
Provider: "How long does the burning sensation last?"
Patient: "It's mostly just when I'm passing urine, but sometimes I feel a little
uncomfortable for a few minutes after."
Provider: "Have you noticed you need to urinate more often than usual?"
