WEEK 2 I HUMAN CASE STUDY:UTI SYMPTOMS AND
ASSESSMENT
1. How can I help you today?
Burning when pee, worried of another bladder infection, symptoms are a little different than the
symptoms I had with my last UTI
2. Do you have any other symptoms or concerns we should discuss? Vaginal discharge
3. Do you have any allergies? NKDA
4. Are your immunizations up to date?
5. When did your pain discomfort with urination start? Three days ago,
6. How severe is your pain discomfort with urination? It makes me not want to go even
though I have to
7. Have you had problems with pain or discomfort with urination like this before? Yes
with my bladder infection last year but this seems different.
8. What is the appearance, smell, texture, and quantity of the vagina discharge?
Yellow, kind of mucousy, kind of creamy and not really too smelly.
,9. Do you have pain with intercourse? Haven’t had sex since this all started. Are you
having or have you had unprotected sex? On pill , so guess I am protected that way. For
STD’s, not so much.
10. DO you use precautions to prevent the transmission of sexual infections: Nothing
other than the pill, taking birth control pills Number of years,
11. Do you have more than one sexual partner? Yes, Heterosexual
12. Have you had any sexually transmitted infections? Not that I know
13. Do you have any vagina discomfort or itching? No
14. Have you had vagina discharge or discomfort like this before? yeast infections but
this is different
15. Does anything make your pain or discomfort with urination better or worse?
Soaking in a warm bath helps.
16. Is your pain or discomfort worse at the start or end of the urination? Worse when
starting but it does not really let up
17. When did your last period begin? About 2 ½ weeks ago
18. Are you sexually active? Yes I am
19. Do you have Neel or multiple sexual partners with similar symptoms? No one has told
me he has any problem.
20. ROS All Body System : Ask 1st question I am a bit worn out from having to get up and
pee all the time it’s hard to get a good nights sleep what else was it that you asked.
21. 2nd question-no problems with an itchy scalp, skin changes, moles, thinning hair or brittle
nails.
, 22. 5th question: chest pain- denies chest pain discomfort or pressure, pain pressure dizziness
with exertion or getting angry, palpitations, decreased exercise tolerance or blue cold
fingers and toes.
23. 6th question SOB, Wheezing: denies shortness of breath, dizzy, difficulty catching breath,
chronic cough or sputum production.
24. 7th question N/V/constipation: denies any problem with nausea, vomiting, constipation,
diarrhea, coffee ground in Walmart, dark tarry stool, bright red blood in bowel
movements, or early satiety or bloating.
25. 9th question: muscle or joint pain denies any problems with muscle or joint pain, redness,
swelling, muscle cramps, chain stiffness, joint swelling or redness, back pain, neck or
shoulder pain or have pain.
26. 11th question: heat or cold intolerance denies any heat or cold intolerance, increased
thirst, increased sweating, frequent urination, or change in appetite.
27. 12th question: denies dizziness, fainting, spinning room, seizures, weakness, numbness,
tingling or tremors.
28. ROS Genitourinary : do you have any genital sores or discharge? No sores but we were
talking about the other.
29. ROS Genitourinary: do you feel when you need to urinate that you need to urgently?
Urgent I know what’s that like I remember when I had that bladder infection when I had
to go I literally had to run to the bathroom I haven’t noticed that so much with this.
30. ROS Genitourinary: Is your urine pink or red in color blood in urine? Haven’t seen
any
ASSESSMENT
1. How can I help you today?
Burning when pee, worried of another bladder infection, symptoms are a little different than the
symptoms I had with my last UTI
2. Do you have any other symptoms or concerns we should discuss? Vaginal discharge
3. Do you have any allergies? NKDA
4. Are your immunizations up to date?
5. When did your pain discomfort with urination start? Three days ago,
6. How severe is your pain discomfort with urination? It makes me not want to go even
though I have to
7. Have you had problems with pain or discomfort with urination like this before? Yes
with my bladder infection last year but this seems different.
8. What is the appearance, smell, texture, and quantity of the vagina discharge?
Yellow, kind of mucousy, kind of creamy and not really too smelly.
,9. Do you have pain with intercourse? Haven’t had sex since this all started. Are you
having or have you had unprotected sex? On pill , so guess I am protected that way. For
STD’s, not so much.
10. DO you use precautions to prevent the transmission of sexual infections: Nothing
other than the pill, taking birth control pills Number of years,
11. Do you have more than one sexual partner? Yes, Heterosexual
12. Have you had any sexually transmitted infections? Not that I know
13. Do you have any vagina discomfort or itching? No
14. Have you had vagina discharge or discomfort like this before? yeast infections but
this is different
15. Does anything make your pain or discomfort with urination better or worse?
Soaking in a warm bath helps.
16. Is your pain or discomfort worse at the start or end of the urination? Worse when
starting but it does not really let up
17. When did your last period begin? About 2 ½ weeks ago
18. Are you sexually active? Yes I am
19. Do you have Neel or multiple sexual partners with similar symptoms? No one has told
me he has any problem.
20. ROS All Body System : Ask 1st question I am a bit worn out from having to get up and
pee all the time it’s hard to get a good nights sleep what else was it that you asked.
21. 2nd question-no problems with an itchy scalp, skin changes, moles, thinning hair or brittle
nails.
, 22. 5th question: chest pain- denies chest pain discomfort or pressure, pain pressure dizziness
with exertion or getting angry, palpitations, decreased exercise tolerance or blue cold
fingers and toes.
23. 6th question SOB, Wheezing: denies shortness of breath, dizzy, difficulty catching breath,
chronic cough or sputum production.
24. 7th question N/V/constipation: denies any problem with nausea, vomiting, constipation,
diarrhea, coffee ground in Walmart, dark tarry stool, bright red blood in bowel
movements, or early satiety or bloating.
25. 9th question: muscle or joint pain denies any problems with muscle or joint pain, redness,
swelling, muscle cramps, chain stiffness, joint swelling or redness, back pain, neck or
shoulder pain or have pain.
26. 11th question: heat or cold intolerance denies any heat or cold intolerance, increased
thirst, increased sweating, frequent urination, or change in appetite.
27. 12th question: denies dizziness, fainting, spinning room, seizures, weakness, numbness,
tingling or tremors.
28. ROS Genitourinary : do you have any genital sores or discharge? No sores but we were
talking about the other.
29. ROS Genitourinary: do you feel when you need to urinate that you need to urgently?
Urgent I know what’s that like I remember when I had that bladder infection when I had
to go I literally had to run to the bathroom I haven’t noticed that so much with this.
30. ROS Genitourinary: Is your urine pink or red in color blood in urine? Haven’t seen
any
