Brianna Gill NR 602: Pain When I Pee – Complete Case Study
Primary Care of the Childbearing and Childbearing Family |
Chamberlain University.
,Case Abstract
Brianna Gill is a 28-year-old female who presents to an outpatient primary care clinic with a
chief complaint of "pain when I pee." She reports a 48-hour history of acute-onset dysuria,
urinary frequency, urgency, and suprapubic discomfort. She is afebrile and denies flank pain,
nausea, vomiting, or vaginal discharge. Her history is notable for inconsistent condom use
with one male partner. Urinalysis reveals pyuria, positive leukocyte esterase, and positive
nitrites. Pregnancy test is negative. The clinical presentation is consistent with acute
uncomplicated lower urinary tract infection (cystitis) . Differential diagnoses include
acute pyelonephritis, sexually transmitted urethritis/cervicitis (Chlamydia
trachomatis, Neisseria gonorrhoeae), vulvovaginitis, nephrolithiasis, and pelvic
inflammatory disease. Treatment is initiated with nitrofurantoin 100 mg PO BID for 5 days.
Patient education focuses on medication adherence, symptom management, prevention
strategies, and return precautions.
Section 1: Reason for Encounter
Demographic Detail
Patient Name Brianna Gill
Age 28 years
Sex Female
Height 5'2" (157 cm)
Weight 132.0 lb (60.0 kg)
BMI 24.3 kg/m²
, Demographic Detail
Outpatient primary care clinic (with x-ray, ECG, and laboratory
Location
capabilities)
Date of Encounter [Current Date]
Source of
Patient (reliable)
Information
Chief Complaint (CC): "Pain when I pee"
Section 2: OLD-CARTS for the History of Presenting Illness (HPI)
Component Patient Response
Onset "It started about 2 days ago, all of a sudden."
"The burning is right around my urethra when I pee, and I have a dull
Location
ache in my lower belly."
Duration "The burning lasts while I'm peeing and goes away right after."
Character "It's a sharp, stinging, burning pain."
Aggravating
"Urinating makes it worse. It's worse when my bladder is full."
Factors
Relieving "The pain stops after I finish peeing. Drinking more water helps a little
Factors bit."
Primary Care of the Childbearing and Childbearing Family |
Chamberlain University.
,Case Abstract
Brianna Gill is a 28-year-old female who presents to an outpatient primary care clinic with a
chief complaint of "pain when I pee." She reports a 48-hour history of acute-onset dysuria,
urinary frequency, urgency, and suprapubic discomfort. She is afebrile and denies flank pain,
nausea, vomiting, or vaginal discharge. Her history is notable for inconsistent condom use
with one male partner. Urinalysis reveals pyuria, positive leukocyte esterase, and positive
nitrites. Pregnancy test is negative. The clinical presentation is consistent with acute
uncomplicated lower urinary tract infection (cystitis) . Differential diagnoses include
acute pyelonephritis, sexually transmitted urethritis/cervicitis (Chlamydia
trachomatis, Neisseria gonorrhoeae), vulvovaginitis, nephrolithiasis, and pelvic
inflammatory disease. Treatment is initiated with nitrofurantoin 100 mg PO BID for 5 days.
Patient education focuses on medication adherence, symptom management, prevention
strategies, and return precautions.
Section 1: Reason for Encounter
Demographic Detail
Patient Name Brianna Gill
Age 28 years
Sex Female
Height 5'2" (157 cm)
Weight 132.0 lb (60.0 kg)
BMI 24.3 kg/m²
, Demographic Detail
Outpatient primary care clinic (with x-ray, ECG, and laboratory
Location
capabilities)
Date of Encounter [Current Date]
Source of
Patient (reliable)
Information
Chief Complaint (CC): "Pain when I pee"
Section 2: OLD-CARTS for the History of Presenting Illness (HPI)
Component Patient Response
Onset "It started about 2 days ago, all of a sudden."
"The burning is right around my urethra when I pee, and I have a dull
Location
ache in my lower belly."
Duration "The burning lasts while I'm peeing and goes away right after."
Character "It's a sharp, stinging, burning pain."
Aggravating
"Urinating makes it worse. It's worse when my bladder is full."
Factors
Relieving "The pain stops after I finish peeing. Drinking more water helps a little
Factors bit."
