IHUMAN CASE STUDY. 28-YEAR-
OLD FAITH WARD. REASON FOR
ENCOUNTER: PAIN WHEN I PEE.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents
Section Title
1 Patient Demographics & Identifying Data
2 Chief Complaint (CC)
3 History of Present Illness (HPI) – The OLD CARTS Method
4 Past Medical History (PMH)
5 Review of Systems (ROS)
6 Social and Family History
7 Physical Examination (PE) – Objective Findings
8 Key Findings & Problem Statement
9 Diagnostic Tests (Labs & Imaging)
10 Differential Diagnosis (DDx)
11 Management Plan (Plan of Care)
12 SOAP Note
, 1. Patient Demographics & Identifying Data
• Name: Faith Ward
• Age: 28-year-old
• Gender: Female
• Date of Visit: __________________
• Source of History: Patient; appears able to provide a clear and reliable
history.
• Reason for Encounter: Pain when urinating.
• Primary Concern: Painful urination that has become bothersome enough
for Faith to seek medical evaluation.
• Mode of Arrival: Presents for evaluation of her urinary discomfort.
• Level of Consciousness: Alert, awake, and appropriately responsive.
• General Appearance: Patient appears mildly uncomfortable but is not in
acute distress. She is appropriately dressed and well groomed.
• Communication: Speech is clear and appropriate, and she is able to
describe her symptoms and concerns.
• Reliability of History: History appears reliable based on the information
provided during the encounter.
• Overall Impression: Faith presents with dysuria (painful urination)
requiring further assessment for a urinary tract infection and other
possible urinary or genitourinary causes.
2. Chief Complaint (CC)
Patient states:
• “It hurts when I pee.”
• Reports a burning or painful sensation during urination.
• The discomfort has become bothersome enough to interfere with her
normal routine.
OLD FAITH WARD. REASON FOR
ENCOUNTER: PAIN WHEN I PEE.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents
Section Title
1 Patient Demographics & Identifying Data
2 Chief Complaint (CC)
3 History of Present Illness (HPI) – The OLD CARTS Method
4 Past Medical History (PMH)
5 Review of Systems (ROS)
6 Social and Family History
7 Physical Examination (PE) – Objective Findings
8 Key Findings & Problem Statement
9 Diagnostic Tests (Labs & Imaging)
10 Differential Diagnosis (DDx)
11 Management Plan (Plan of Care)
12 SOAP Note
, 1. Patient Demographics & Identifying Data
• Name: Faith Ward
• Age: 28-year-old
• Gender: Female
• Date of Visit: __________________
• Source of History: Patient; appears able to provide a clear and reliable
history.
• Reason for Encounter: Pain when urinating.
• Primary Concern: Painful urination that has become bothersome enough
for Faith to seek medical evaluation.
• Mode of Arrival: Presents for evaluation of her urinary discomfort.
• Level of Consciousness: Alert, awake, and appropriately responsive.
• General Appearance: Patient appears mildly uncomfortable but is not in
acute distress. She is appropriately dressed and well groomed.
• Communication: Speech is clear and appropriate, and she is able to
describe her symptoms and concerns.
• Reliability of History: History appears reliable based on the information
provided during the encounter.
• Overall Impression: Faith presents with dysuria (painful urination)
requiring further assessment for a urinary tract infection and other
possible urinary or genitourinary causes.
2. Chief Complaint (CC)
Patient states:
• “It hurts when I pee.”
• Reports a burning or painful sensation during urination.
• The discomfort has become bothersome enough to interfere with her
normal routine.
