iHuman Case Study: Acute Uncomplicated Cystitis in a 24-Year-Old Female

IHUMAN BRIANNA GILL CASE STUDY: DYSURIA
(PAINFUL URINATION)
ASSESSMENT, DIFFERENTIAL DIAGNOSIS & SOAP
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,Patient Profile

Name: Brianna Gill
Age: 24 years
Sex: Female
Chief Complaint: "It burns when I urinate."



History of Present Illness (HPI)

Brianna Gill is a 24-year-old female presenting with a 3-day history of painful urination (dysuria).
She reports a burning sensation during urination accompanied by urinary frequency and
urgency. She denies flank pain, fever, chills, nausea, vomiting, or vaginal discharge. Symptoms
have progressively worsened over the past three days.

She states that she recently became sexually active with a new partner and occasionally uses
condoms. She has no previous history of kidney stones or recurrent urinary tract infections.

OLDCARTS

Component Description

Onset 3 days ago

Location Suprapubic area and urethra

Duration Constant

Character Burning pain with urination

Aggravating Factors Voiding

Relieving Factors Drinking water provides minimal relief

Radiation None

Timing Worse toward the end of urination

Severity 5/10

, Review of Systems (ROS)

Constitutional

• No fever

• No chills

• No weight loss

Genitourinary

• Dysuria

• Frequency

• Urgency

• Mild suprapubic discomfort

• No hematuria

• No vaginal discharge

• No flank pain

Gastrointestinal

• No nausea

• No vomiting

• No abdominal pain

Musculoskeletal

• No back pain

Respiratory

• No cough

• No shortness of breath

Cardiovascular

• No chest pain



Past Medical History