UTI & STI Case Study | i-Human Nursing & Medical Student SOAP Note | 16-Year-Old Dysuria PDF | Cystitis vs Urethritis

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IHUMAN CASE STUDY FOR A 16 YEARS OLD PATIENT -
REASON FOR ENCOUNTER: “I’M PEEING A LOT AND
IT HURTS” - WEEK #7 2026 (CLASS 6512) LOCATION:
OUTPATIENT CLINIC WITH X-RAY, ECG, AND
LABORATORY SERVICES

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Case title & summary:
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Acute urinary symptoms (frequency + dysuria) in an 16-year-old — evaluation
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g; focuses on distinguishing uncomplicated lower urinary tract infection (cystitis)
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g; from sexually-transmitted urethritis, pyelonephritis, pregnancy-related infection,
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g; nephrolithiasis, metabolic causes (diabetes), and less common causes such as
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g; interstitial cystitis. Includes urgent tests (pregnancy test, urine dip/UA, NAAT
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for STIs), empiric therapy considerations, and safety netting.
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Reason for encounter: g; g;



“Peeing a lot and it hurts” — parent/patient worried; started within past 48 hours,
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g; interfering with school and sleep.
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Patient demographics: g;




• Age: 16 years g; g;



• Sex: g ; female
• Height: 5′4″ (163 cm) g; g; g;



• Weight: 125 lb (56.8 kg) g; g; g; g;



• BMI: ~21.3 kg/m² g; g;




Case mode: Learning mode
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Clinic capabilities: X-ray, ECG, point-of-care urine dip, lab UA + culture, NAAT
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g; for chlamydia/gonorrhea, pregnancy testing, basic metabolic panel.
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Attempts allowed: Unlimited (learning)
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2) Chief Complaint (CC)
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Patient states: “I’m peeing a lot and it hurts.”
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• Onset: 48 hours ago g; g; g;



• Course: progressive — frequency increasing, dysuria persistent
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• Severity: moderate (interferes with class and sleep)
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• Key associated complaint to probe: vaginal discharge, fever, flank pain,
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g; nausea/vomiting, sexual activity, new partners, contraception, last g; g; g; g; g; g;



menstrual period (LMP).
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3) History of Present Illness (HPI)
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• Symptom detail: Dysuria (burning at urethral meatus when voiding),
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g; urinary frequency (voiding every 30–60 minutes), urgency, small
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g; volumes, nocturia interrupting sleep. Reports suprapubic pressure,
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g; denies gross hematuria (no visible blood, but may have microscopic).
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g; No flank pain at present. No nausea/vomiting.
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• Timing: Started 2 days ago after social weekend; no clear trauma.
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• Associated: Slight malodorous urine per patient; denies fever or chills
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(take temp). No skin rash. Reports mild vaginal irritation but no profuse
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g; foul discharge.g;



• Obstetric/menstrual: LMP 10 days ago, regular 28-day cycles. g; g; g; g; g; g; g;



g; Sexually active; last intercourse 6 days ago with a new partner;
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g; inconsistent condom use. No current contraception other than condoms.
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