IHUMAN CASE STUDY WEEK 7 16 YEAR OLD
FEMALE CHIEF COMPLAINT; ‘’IM PEEING A
LOT AND IT HUR, Exams of Health sciences
Activity 1: Patient Biodata and Clinical History
In clinical practice, the first step in diagnosing a patient is gathering accurate biodata and a detailed
History of Present Illness (HPI). Review the patient profile below, which has been compiled from the
initial intake at the outpatient clinic.
Patient Biodata
Name (Pseudonym) Chloe Miller
Age 16
Gender Female
Chief Complaint "I'm peeing a lot and it hurts."
, Clinical Setting Outpatient Clinic
Clinical Terminology
Dysuria: Painful or difficult urination. Frequency: The need to urinate more often than usual. Urgency:
A sudden, strong need to urinate immediately.
History of Present Illness (HPI)
The patient is an 18-year-old female who presents to the outpatient clinic with a 48-hour
history of increasing urinary frequency and significant dysuria. She describes the pain as a
"burning sensation" that occurs primarily at the end of the urinary stream. She reports
needing to use the restroom every 30 to 60 minutes, often passing only small amounts of
urine.
Critically, the patient denies experiencing any fever, chills, or nausea. She also reports no
back or flank pain (negative CVA tenderness). She notes that her urine has appeared
somewhat cloudy and has a stronger odor than usual, but she has not observed any visible
blood. The absence of systemic symptoms like fever and the lack of upper-quadrant or back
pain suggests that the infection is localized to the lower urinary tract.
Critical Thinking Question: Based on the HPI provided, why is the lack of fever and back pain a
significant finding for a healthcare provider when considering a diagnosis of a Lower Urinary Tract
Infection (Cystitis) versus an Upper Urinary Tract Infection (Pyelonephritis)?
Activity 2: SOAPstone Analysis
In clinical communication, understanding the context of an encounter is as important as the medical
data itself. The SOAPstone method is a tool used to analyze the components of a communication act.
Directions: Using the History of Present Illness (HPI) from Activity 1, complete the SOAPstone
graphic organizer below. Identify each element of the clinical encounter between the 18-year-old
patient and the healthcare provider.
Element Clinical Analysis (Evidence) Model Answer
FEMALE CHIEF COMPLAINT; ‘’IM PEEING A
LOT AND IT HUR, Exams of Health sciences
Activity 1: Patient Biodata and Clinical History
In clinical practice, the first step in diagnosing a patient is gathering accurate biodata and a detailed
History of Present Illness (HPI). Review the patient profile below, which has been compiled from the
initial intake at the outpatient clinic.
Patient Biodata
Name (Pseudonym) Chloe Miller
Age 16
Gender Female
Chief Complaint "I'm peeing a lot and it hurts."
, Clinical Setting Outpatient Clinic
Clinical Terminology
Dysuria: Painful or difficult urination. Frequency: The need to urinate more often than usual. Urgency:
A sudden, strong need to urinate immediately.
History of Present Illness (HPI)
The patient is an 18-year-old female who presents to the outpatient clinic with a 48-hour
history of increasing urinary frequency and significant dysuria. She describes the pain as a
"burning sensation" that occurs primarily at the end of the urinary stream. She reports
needing to use the restroom every 30 to 60 minutes, often passing only small amounts of
urine.
Critically, the patient denies experiencing any fever, chills, or nausea. She also reports no
back or flank pain (negative CVA tenderness). She notes that her urine has appeared
somewhat cloudy and has a stronger odor than usual, but she has not observed any visible
blood. The absence of systemic symptoms like fever and the lack of upper-quadrant or back
pain suggests that the infection is localized to the lower urinary tract.
Critical Thinking Question: Based on the HPI provided, why is the lack of fever and back pain a
significant finding for a healthcare provider when considering a diagnosis of a Lower Urinary Tract
Infection (Cystitis) versus an Upper Urinary Tract Infection (Pyelonephritis)?
Activity 2: SOAPstone Analysis
In clinical communication, understanding the context of an encounter is as important as the medical
data itself. The SOAPstone method is a tool used to analyze the components of a communication act.
Directions: Using the History of Present Illness (HPI) from Activity 1, complete the SOAPstone
graphic organizer below. Identify each element of the clinical encounter between the 18-year-old
patient and the healthcare provider.
Element Clinical Analysis (Evidence) Model Answer
