I HUMAN CASE STUDY 62 YEAR OLD REASON FOR
ENCOUNTER’ FREQUENT URINATION’ HEAD TO TOE
ASSESSMENT WITH SOAP NOTE REAL 2025!!!! latest
,62-Year-Old – Reason for Encounter: Frequent Urination
HISTORY + HEAD-TO-TOE ASSESSMENT (Complete Template)
1. Chief Complaint (CC)
“I'm urinating too often.”
2. History of Present Illness (HPI)
The patient is a 62-year-old male/female presenting with a gradual onset of frequent urination for the
past X days/weeks (fill based on case).
They report:
• Increased urinary frequency (describe: every hour, nocturia, etc.)
• Urine volume (large amounts? small dribbles?)
• Onset: when it started
• Associated symptoms
o Burning or pain during urination (dysuria)
o Urgency
o Hesitancy
o Weak stream
o Incomplete emptying
o Hematuria
o Fever, chills
o Low back or flank pain
o Pelvic discomfort
• Aggravating factors
• Relieving factors
• Hydration level (↑ water? caffeine?)
• Recent medication changes
• History of UTIs, kidney stones, prostate issues (if male)
, • Blood sugars / diabetes symptoms
o Excessive thirst
o Unintentional weight loss
o Blurry vision
o Fatigue
3. Past Medical History (PMH)
Include typical options for a 62-year-old iHuman case:
• Hypertension
• Diabetes mellitus (type II)
• Hyperlipidemia
• BPH (if male)
• Recurrent UTIs
• Kidney stones
• Osteoarthritis
• Cardiovascular disease
• Any hospitalizations
• Any surgeries
o Prostate surgery?
o Kidney/ureter procedures?
4. Medications
List common possibilities:
• Antihypertensives
• Metformin or other diabetes meds
• Diuretics (can cause frequency!)
• Antibiotics (recent?)
• Anticholinergics
• NSAIDs
ENCOUNTER’ FREQUENT URINATION’ HEAD TO TOE
ASSESSMENT WITH SOAP NOTE REAL 2025!!!! latest
,62-Year-Old – Reason for Encounter: Frequent Urination
HISTORY + HEAD-TO-TOE ASSESSMENT (Complete Template)
1. Chief Complaint (CC)
“I'm urinating too often.”
2. History of Present Illness (HPI)
The patient is a 62-year-old male/female presenting with a gradual onset of frequent urination for the
past X days/weeks (fill based on case).
They report:
• Increased urinary frequency (describe: every hour, nocturia, etc.)
• Urine volume (large amounts? small dribbles?)
• Onset: when it started
• Associated symptoms
o Burning or pain during urination (dysuria)
o Urgency
o Hesitancy
o Weak stream
o Incomplete emptying
o Hematuria
o Fever, chills
o Low back or flank pain
o Pelvic discomfort
• Aggravating factors
• Relieving factors
• Hydration level (↑ water? caffeine?)
• Recent medication changes
• History of UTIs, kidney stones, prostate issues (if male)
, • Blood sugars / diabetes symptoms
o Excessive thirst
o Unintentional weight loss
o Blurry vision
o Fatigue
3. Past Medical History (PMH)
Include typical options for a 62-year-old iHuman case:
• Hypertension
• Diabetes mellitus (type II)
• Hyperlipidemia
• BPH (if male)
• Recurrent UTIs
• Kidney stones
• Osteoarthritis
• Cardiovascular disease
• Any hospitalizations
• Any surgeries
o Prostate surgery?
o Kidney/ureter procedures?
4. Medications
List common possibilities:
• Antihypertensives
• Metformin or other diabetes meds
• Diuretics (can cause frequency!)
• Antibiotics (recent?)
• Anticholinergics
• NSAIDs
