i-Human Brianna Gill Case Study Pain When I Pee
Chamberlain NR-602 — Primary Care of the Childbearing
& Childbearing Family
,1. CASE ABSTRACT
Patient: Brianna Gill
Chief Complaint: Pain when urinating
Primary symptom: Dysuria
Course: Acute urinary/genitourinary complaint
Clinical setting: Primary care
Course: NR-602 — Primary Care of the Childbearing & Childbearing Family
Encounter focus: Comprehensive evaluation of dysuria in a reproductive-
age/childbearing patient.
Brianna Gill presents to primary care with painful urination (dysuria). Because
dysuria may result from lower urinary tract infection, urethritis, sexually
transmitted infection, vaginitis, genital irritation, nephrolithiasis, pyelonephritis, or
pregnancy-associated conditions, the clinician should not immediately assume
uncomplicated cystitis.
The evaluation begins with a detailed history of present illness, including onset,
duration, urinary frequency, urgency, hematuria, suprapubic discomfort, fever,
chills, flank pain, nausea/vomiting, vaginal discharge, vaginal irritation, pelvic
pain, sexual history, contraception, last menstrual period, pregnancy possibility,
previous urinary infections, medications, allergies, and relevant medical history.
The physical examination focuses on vital signs, general appearance, abdomen,
suprapubic region, costovertebral angles, and pelvic examination when indicated.
Diagnostic evaluation may include urinalysis, urine culture, pregnancy testing,
STI testing, and additional testing based on symptoms and risk factors.
The primary working diagnosis in a clinically appropriate presentation is acute
cystitis, but pyelonephritis, urethritis/STI, vaginitis, nephrolithiasis, and
pregnancy-related pathology must be considered.
2. PATIENT PROFILE
Category Case information
Patient Brianna Gill
Sex Female
,Category Case information
Age Childbearing-age adult
Course NR-602
Course title Primary Care of the Childbearing & Childbearing Family
Date/context June 2026
Setting Primary care
Chief complaint Pain when urinating
Medical term Dysuria
Historian Patient
Primary concern Determine source of dysuria
Primary differential Cystitis vs urethritis/vaginitis vs upper urinary disease
3. CHIEF COMPLAINT — CC
Patient statement:
“It hurts when I pee.”
Clinical terminology:
Dysuria
4. HISTORY OF PRESENT ILLNESS — HPI
Brianna Gill presents to primary care reporting painful urination.
The clinician should establish:
• When symptoms began
• Whether onset was sudden or gradual
• Whether symptoms are worsening
, • Frequency of urination
• Urinary urgency
• Nocturia
• Hematuria
• Suprapubic pain
• Flank/back pain
• Fever or chills
• Nausea/vomiting
• Vaginal discharge
• Vaginal itching or irritation
• Pelvic pain
• Dyspareunia
• Recent sexual activity
• New sexual partner
• Previous UTIs
• Recent antibiotics
• Pregnancy possibility
Example reconstructed HPI
Brianna reports an acute onset of burning/pain with urination accompanied by
increased urinary frequency and urgency. She describes discomfort primarily
during urination and reports lower urinary discomfort without evidence of severe
systemic illness in the reconstructed presentation.
The clinician should specifically ask about fever, chills, flank pain, vomiting,
vaginal discharge, abnormal vaginal bleeding, pelvic pain, pregnancy possibility,
and STI exposure before establishing the diagnosis.
5. HPI — OPQRST
Chamberlain NR-602 — Primary Care of the Childbearing
& Childbearing Family
,1. CASE ABSTRACT
Patient: Brianna Gill
Chief Complaint: Pain when urinating
Primary symptom: Dysuria
Course: Acute urinary/genitourinary complaint
Clinical setting: Primary care
Course: NR-602 — Primary Care of the Childbearing & Childbearing Family
Encounter focus: Comprehensive evaluation of dysuria in a reproductive-
age/childbearing patient.
Brianna Gill presents to primary care with painful urination (dysuria). Because
dysuria may result from lower urinary tract infection, urethritis, sexually
transmitted infection, vaginitis, genital irritation, nephrolithiasis, pyelonephritis, or
pregnancy-associated conditions, the clinician should not immediately assume
uncomplicated cystitis.
The evaluation begins with a detailed history of present illness, including onset,
duration, urinary frequency, urgency, hematuria, suprapubic discomfort, fever,
chills, flank pain, nausea/vomiting, vaginal discharge, vaginal irritation, pelvic
pain, sexual history, contraception, last menstrual period, pregnancy possibility,
previous urinary infections, medications, allergies, and relevant medical history.
The physical examination focuses on vital signs, general appearance, abdomen,
suprapubic region, costovertebral angles, and pelvic examination when indicated.
Diagnostic evaluation may include urinalysis, urine culture, pregnancy testing,
STI testing, and additional testing based on symptoms and risk factors.
The primary working diagnosis in a clinically appropriate presentation is acute
cystitis, but pyelonephritis, urethritis/STI, vaginitis, nephrolithiasis, and
pregnancy-related pathology must be considered.
2. PATIENT PROFILE
Category Case information
Patient Brianna Gill
Sex Female
,Category Case information
Age Childbearing-age adult
Course NR-602
Course title Primary Care of the Childbearing & Childbearing Family
Date/context June 2026
Setting Primary care
Chief complaint Pain when urinating
Medical term Dysuria
Historian Patient
Primary concern Determine source of dysuria
Primary differential Cystitis vs urethritis/vaginitis vs upper urinary disease
3. CHIEF COMPLAINT — CC
Patient statement:
“It hurts when I pee.”
Clinical terminology:
Dysuria
4. HISTORY OF PRESENT ILLNESS — HPI
Brianna Gill presents to primary care reporting painful urination.
The clinician should establish:
• When symptoms began
• Whether onset was sudden or gradual
• Whether symptoms are worsening
, • Frequency of urination
• Urinary urgency
• Nocturia
• Hematuria
• Suprapubic pain
• Flank/back pain
• Fever or chills
• Nausea/vomiting
• Vaginal discharge
• Vaginal itching or irritation
• Pelvic pain
• Dyspareunia
• Recent sexual activity
• New sexual partner
• Previous UTIs
• Recent antibiotics
• Pregnancy possibility
Example reconstructed HPI
Brianna reports an acute onset of burning/pain with urination accompanied by
increased urinary frequency and urgency. She describes discomfort primarily
during urination and reports lower urinary discomfort without evidence of severe
systemic illness in the reconstructed presentation.
The clinician should specifically ask about fever, chills, flank pain, vomiting,
vaginal discharge, abnormal vaginal bleeding, pelvic pain, pregnancy possibility,
and STI exposure before establishing the diagnosis.
5. HPI — OPQRST
