Brianna Gill NR 602: Pain When I Pee – Complete Case
Study Primary Care of the Childbearing and
Childbearing Family | Chamberlain University Pain
When I Pee: A Case Study in Differential Diagnosis of
Dysuria in a 28-Year-Old Female
,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. Serum β-hCG 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 (candidiasis, bacterial vaginosis,
trichomoniasis), 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. This case
study demonstrates the importance of a thorough history, including a comprehensive sexual
history, to differentiate UTI from STI co-infections in sexually active young women.
Patient Profile
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
Ethnicity [Not specified]
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"
History of Presenting Illness (HPI)
Brianna Gill is a 28-year-old female who presents to the outpatient primary care clinic with a
chief complaint of dysuria, urinary frequency, and lower abdominal discomfort. She reports
that her symptoms began approximately 48 hours ago, with an acute onset of burning pain
localized to the urethra and suprapubic area during urination.
OPQRST/OLDCARTS Analysis
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."
Radiation "No, it stays in my lower belly and urethra."
"It happens every time I pee. I've been going to the bathroom every 1-2
Timing
hours, and I wake up 2-3 times at night to go."
"I'd rate it a 6 out of 10. It's bad enough that I dread going to the
Severity
bathroom."
Urinary Symptom Analysis
Symptom Present Details
Dysuria Burning, stinging pain during urination; 6/10 severity
, Symptom Present Details
Urinary Frequency Voiding every 1-2 hours (baseline every 4-6 hours)
Urinary Urgency Sudden, strong urge to urinate difficult to delay
Nocturia Waking 2-3 times per night to urinate (baseline 0-1)
Suprapubic Dull aching sensation in lower abdomen between
Discomfort voids
Hematuria No gross hematuria reported
Incontinence No accidental urine leakage
Hesitancy No difficulty starting urine stream
Associated Symptoms (Denied)
• Fever, chills, or night sweats
• Nausea or vomiting
• Flank or back pain
• Passage of stones or blood clots
• Abnormal vaginal discharge, odor, or itching
• Dyspareunia
• Postcoital bleeding
Prior Interventions
None for this episode. Reports one prior UTI approximately 2 years ago, treated with an
antibiotic (unable to recall specific medication). Has tried increasing water intake, which
provides minimal relief. Has not taken any over-the-counter medications.
Past Medical History (PMH)
Category Details
None chronic. One prior UTI (2 years ago), resolved with
Medical Conditions
antibiotics.
Surgical History None
Study Primary Care of the Childbearing and
Childbearing Family | Chamberlain University Pain
When I Pee: A Case Study in Differential Diagnosis of
Dysuria in a 28-Year-Old Female
,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. Serum β-hCG 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 (candidiasis, bacterial vaginosis,
trichomoniasis), 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. This case
study demonstrates the importance of a thorough history, including a comprehensive sexual
history, to differentiate UTI from STI co-infections in sexually active young women.
Patient Profile
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
Ethnicity [Not specified]
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"
History of Presenting Illness (HPI)
Brianna Gill is a 28-year-old female who presents to the outpatient primary care clinic with a
chief complaint of dysuria, urinary frequency, and lower abdominal discomfort. She reports
that her symptoms began approximately 48 hours ago, with an acute onset of burning pain
localized to the urethra and suprapubic area during urination.
OPQRST/OLDCARTS Analysis
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."
Radiation "No, it stays in my lower belly and urethra."
"It happens every time I pee. I've been going to the bathroom every 1-2
Timing
hours, and I wake up 2-3 times at night to go."
"I'd rate it a 6 out of 10. It's bad enough that I dread going to the
Severity
bathroom."
Urinary Symptom Analysis
Symptom Present Details
Dysuria Burning, stinging pain during urination; 6/10 severity
, Symptom Present Details
Urinary Frequency Voiding every 1-2 hours (baseline every 4-6 hours)
Urinary Urgency Sudden, strong urge to urinate difficult to delay
Nocturia Waking 2-3 times per night to urinate (baseline 0-1)
Suprapubic Dull aching sensation in lower abdomen between
Discomfort voids
Hematuria No gross hematuria reported
Incontinence No accidental urine leakage
Hesitancy No difficulty starting urine stream
Associated Symptoms (Denied)
• Fever, chills, or night sweats
• Nausea or vomiting
• Flank or back pain
• Passage of stones or blood clots
• Abnormal vaginal discharge, odor, or itching
• Dyspareunia
• Postcoital bleeding
Prior Interventions
None for this episode. Reports one prior UTI approximately 2 years ago, treated with an
antibiotic (unable to recall specific medication). Has tried increasing water intake, which
provides minimal relief. Has not taken any over-the-counter medications.
Past Medical History (PMH)
Category Details
None chronic. One prior UTI (2 years ago), resolved with
Medical Conditions
antibiotics.
Surgical History None
