Brianna Gill – "Pain When I Pee": Full
History & Physical Encounter | Chamberlain
NR602
BRIANNA GILL – Comprehensive i-Human Case Study
NR602 Primary Care of the Childbearing and Childrearing Family
,I. PATIENT INFORMATION
Field Details
Name Brianna Gill
Age 28 years
Sex Female
Ethnicity Caucasian
Height 5' 2" (157 cm)
Weight 132.0 lb (60.0 kg)
BMI 24.1 (Normal)
Setting Outpatient Primary Care Clinic
Source Patient
II. CHIEF COMPLAINT (CC)
"It hurts when I pee"
Patient reports dysuria (painful urination), urinary frequency, and suprapubic
discomfort. She describes her urine as cloudy and malodorous .
III. HISTORY OF PRESENTING ILLNESS (HPI) – OLD-CARTS Format
,Component Details
Onset Began approximately 48 hours ago; gradual onset with increasing intensi
Burning sensation at urethral opening during urination; dull, aching pain
Location
in suprapubic/pelvic area (deep in pelvis)
Sharp pain lasts throughout voiding; dull pelvic ache is constant most of
Duration
time
Character Sharp, burning sensation during urination (classic dysuria)
Aggravating
Urination triggers sharp pain; movement worsens pelvic pressure
Factors
Relieving Heating pad on abdomen provides mild relief for pelvic ache; ibuprofen
Factors provided minimal relief
Timing Symptoms are consistent throughout the day; occurs every time she voi
Severity 7/10 pain during voiding; lower intensity for dull ache
Associated Symptoms
• Urinary frequency – feels the urge to void every 30 minutes
• Urgency – strong, sudden need to urinate
• Cloudy, malodorous urine
• Suprapubic pressure/pain
• No gross hematuria (no visible blood in urine)
Pertinent Negatives
, System Negative Finding
Genitourinary No vaginal discharge, no itching
Genitourinary No visible blood in urine
Gastrointestinal No nausea, vomiting, or diarrhea
Systemic No fever, chills, or night sweats
Renal No flank pain (rules out pyelonephritis)
IV. REVIEW OF SYSTEMS (ROS)
System Findings
General No weight changes, no fatigue, overall feels normal
Integumentary No new rashes or skin changes
HEENT No headaches, no vision changes
Respiratory No shortness of breath or cough
Cardiovascular No chest pain or palpitations
Gastrointestinal Suprapubic pressure only (no nausea/vomiting)
Genitourinary Dysuria, frequency, urgency; cloudy/malodorous urine
Musculoskeletal No joint pain or muscle aches
Neurological No headaches, dizziness, or paresthesias
History & Physical Encounter | Chamberlain
NR602
BRIANNA GILL – Comprehensive i-Human Case Study
NR602 Primary Care of the Childbearing and Childrearing Family
,I. PATIENT INFORMATION
Field Details
Name Brianna Gill
Age 28 years
Sex Female
Ethnicity Caucasian
Height 5' 2" (157 cm)
Weight 132.0 lb (60.0 kg)
BMI 24.1 (Normal)
Setting Outpatient Primary Care Clinic
Source Patient
II. CHIEF COMPLAINT (CC)
"It hurts when I pee"
Patient reports dysuria (painful urination), urinary frequency, and suprapubic
discomfort. She describes her urine as cloudy and malodorous .
III. HISTORY OF PRESENTING ILLNESS (HPI) – OLD-CARTS Format
,Component Details
Onset Began approximately 48 hours ago; gradual onset with increasing intensi
Burning sensation at urethral opening during urination; dull, aching pain
Location
in suprapubic/pelvic area (deep in pelvis)
Sharp pain lasts throughout voiding; dull pelvic ache is constant most of
Duration
time
Character Sharp, burning sensation during urination (classic dysuria)
Aggravating
Urination triggers sharp pain; movement worsens pelvic pressure
Factors
Relieving Heating pad on abdomen provides mild relief for pelvic ache; ibuprofen
Factors provided minimal relief
Timing Symptoms are consistent throughout the day; occurs every time she voi
Severity 7/10 pain during voiding; lower intensity for dull ache
Associated Symptoms
• Urinary frequency – feels the urge to void every 30 minutes
• Urgency – strong, sudden need to urinate
• Cloudy, malodorous urine
• Suprapubic pressure/pain
• No gross hematuria (no visible blood in urine)
Pertinent Negatives
, System Negative Finding
Genitourinary No vaginal discharge, no itching
Genitourinary No visible blood in urine
Gastrointestinal No nausea, vomiting, or diarrhea
Systemic No fever, chills, or night sweats
Renal No flank pain (rules out pyelonephritis)
IV. REVIEW OF SYSTEMS (ROS)
System Findings
General No weight changes, no fatigue, overall feels normal
Integumentary No new rashes or skin changes
HEENT No headaches, no vision changes
Respiratory No shortness of breath or cough
Cardiovascular No chest pain or palpitations
Gastrointestinal Suprapubic pressure only (no nausea/vomiting)
Genitourinary Dysuria, frequency, urgency; cloudy/malodorous urine
Musculoskeletal No joint pain or muscle aches
Neurological No headaches, dizziness, or paresthesias
