Student Name: Alixandra Messer
Course: MSN 650L
Today’s date: 3/27/26
======================================================================================
Demographics:
Patient Initials: TS
Age: 38 years old
Gender: Female
Pronouns: She/her
Visit Date: 3/25/26
Clinical Location: Triad Health Systems
SUBJECTIVE:
Chief Complaint: “I have burning when I pee, and I feel like I have to go all the time.”
Source & Reliability of History:
HPI: TS is a 38-year-old female who presents to the clinic with complaints of dysuria and urinary frequency for the past 2
days. The pain has been intermittent since it started 2 days ago but today is more consistent. Voiding makes the pain
worse. Patient has attempted to increase water intake, Tylenol PRN for pain and OTC Azo urinary pain relief tablets with
some relief. TS rates the pain 5/10 on the pain scale. TS denies fever, chills, nausea, vomiting, flank pain, vaginal
discharge, or abnormal bleeding. Patient denies recent sexual intercourse, and is married with two children.
Onset: 2 days ago
Location: suprapubic region
Duration: intermittent since onset, but today more consistent
Characteristics: Burning sensation and discomfort with urination
Aggravating: Voiding
Relieving: No relieving factors
Treatments attempted: Attempted to increase water intake and OTC AZO with some improvement
Pain Scale: 5/10
, Any additional narrative: The patient denies fever, chills, nausea, vomiting, flank pain, vaginal discharge, or
abnormal bleeding. History includes one UTI about 10 years ago. Patient reports no sexual intercourse in 4 months
and is married with two children. No recent antibiotic use.
PMH: No past medical history or chronic conditions.
PSH: (Surgical history): Hysterectomy in 2020
Family History:
Mother: Hypertension (Living)
Father: Type 2 diabetes (Living)
Maternal Grandmother: Hypertension (Deceased)
Maternal Grandfather: Type 2 diabetes (Deceased)
Brother: Hypertension (Living)
No other family history of medical conditions.
Social determinants of health:
Tobacco: Denies tobacco use.
Alcohol: Occasional alcohol use on the weekends with friends. 1-2 glasses of wine.
Illicit drug: Denies illicit drug use.
Environmental exposures: None
Safety Assessment: Depression Screening PHQ9: N/A
Reports feeling safe at home: Yes
Living situation: Living in house with spouse and two young children.
Vaccinations/Immunizations:
Childhood immunizations complete
Influenza Vaccine: Given October 2025
Occupation: 1st grade school teacher
For Children: N/A
For Infants: N/A
For children: N/A
For Teens: N/A
Course: MSN 650L
Today’s date: 3/27/26
======================================================================================
Demographics:
Patient Initials: TS
Age: 38 years old
Gender: Female
Pronouns: She/her
Visit Date: 3/25/26
Clinical Location: Triad Health Systems
SUBJECTIVE:
Chief Complaint: “I have burning when I pee, and I feel like I have to go all the time.”
Source & Reliability of History:
HPI: TS is a 38-year-old female who presents to the clinic with complaints of dysuria and urinary frequency for the past 2
days. The pain has been intermittent since it started 2 days ago but today is more consistent. Voiding makes the pain
worse. Patient has attempted to increase water intake, Tylenol PRN for pain and OTC Azo urinary pain relief tablets with
some relief. TS rates the pain 5/10 on the pain scale. TS denies fever, chills, nausea, vomiting, flank pain, vaginal
discharge, or abnormal bleeding. Patient denies recent sexual intercourse, and is married with two children.
Onset: 2 days ago
Location: suprapubic region
Duration: intermittent since onset, but today more consistent
Characteristics: Burning sensation and discomfort with urination
Aggravating: Voiding
Relieving: No relieving factors
Treatments attempted: Attempted to increase water intake and OTC AZO with some improvement
Pain Scale: 5/10
, Any additional narrative: The patient denies fever, chills, nausea, vomiting, flank pain, vaginal discharge, or
abnormal bleeding. History includes one UTI about 10 years ago. Patient reports no sexual intercourse in 4 months
and is married with two children. No recent antibiotic use.
PMH: No past medical history or chronic conditions.
PSH: (Surgical history): Hysterectomy in 2020
Family History:
Mother: Hypertension (Living)
Father: Type 2 diabetes (Living)
Maternal Grandmother: Hypertension (Deceased)
Maternal Grandfather: Type 2 diabetes (Deceased)
Brother: Hypertension (Living)
No other family history of medical conditions.
Social determinants of health:
Tobacco: Denies tobacco use.
Alcohol: Occasional alcohol use on the weekends with friends. 1-2 glasses of wine.
Illicit drug: Denies illicit drug use.
Environmental exposures: None
Safety Assessment: Depression Screening PHQ9: N/A
Reports feeling safe at home: Yes
Living situation: Living in house with spouse and two young children.
Vaccinations/Immunizations:
Childhood immunizations complete
Influenza Vaccine: Given October 2025
Occupation: 1st grade school teacher
For Children: N/A
For Infants: N/A
For children: N/A
For Teens: N/A
