WARD, 28-YEAR-OLD, REASON
FOR ENCOUNTER: PAIN WHEN I
PEE.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents
Section Title
1 History
2 PHYSICAL EXAMINATION (PE) – Objective Findings
3 Assessment
4 TEST RESULTS (Diagnostic Investigations)
5 Diagnosis: Primary Diagnosis & Differential Diagnosis:
6 MANAGEMENT PLAN (PLAN OF CARE)
7 Summary
8 Soap Note
, 1. HISTORY
Patient Demographics & Identifying Information
• Name: Faith Ward
• Age: 28-year-old
• Gender: Female
• Reason for Encounter: Pain when urinating
• Source of History: Patient
• Reliability: Patient appears able to provide information about her
current symptoms.
Presenting Concern
Faith Ward presents with pain when urinating, describing discomfort
associated with passing urine. The urinary pain has become concerning enough
for her to seek medical evaluation.
She reports that urination is uncomfortable and that the symptoms are
affecting her normal routine. Her presentation raises concern for a possible
urinary tract infection or other urinary tract condition.
Current Symptoms
Faith's main complaint is pain or burning during urination. The discomfort is
specifically associated with voiding rather than being constant throughout the
day.
The history should also assess for associated urinary symptoms such as:
• Increased urinary frequency.
• Urinary urgency.
• Passing small amounts of urine.
• Lower abdominal or pelvic discomfort.
• Cloudy or strong-smelling urine.
• Blood in the urine.