I-HUMAN COMPREHENSIVE
CASE STUDY. FAITH WARD 28-
YEAR-OLD. REASON FOR
ENCOUNTER: PAIN WHEN I
PEE.
WITH A SOAP NOTE.
EXAM STUDY GUIDE. GRADED
A+. LATEST 2026/2027
UPDATE.
,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.
• She is concerned that she may have a urinary infection and would like to
know what is causing the pain.
3. History of Present Illness (HPI) – OLD CARTS Method
O – Onset
• Faith reports that the pain with urination started recently.
• The discomfort was initially mild but has become more noticeable.
CASE STUDY. FAITH WARD 28-
YEAR-OLD. REASON FOR
ENCOUNTER: PAIN WHEN I
PEE.
WITH A SOAP NOTE.
EXAM STUDY GUIDE. GRADED
A+. LATEST 2026/2027
UPDATE.
,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.
• She is concerned that she may have a urinary infection and would like to
know what is causing the pain.
3. History of Present Illness (HPI) – OLD CARTS Method
O – Onset
• Faith reports that the pain with urination started recently.
• The discomfort was initially mild but has become more noticeable.
