YEAR OLD FEMALE PRESENTING WITH DYSURIA
AND URINARY FREQUENCY CONSISTENT WITH
ACUTE UNCOMPLICATED UTI AT OUTPATIENT
PRIMARY CARE CLINIC
,PATIENT INFORMATION
• Age: 24 years
• Sex: Female
• Height: 5′3″ (160 cm)
• Weight: 130 lb (59 kg)
• Location: Outpatient primary care clinic
• Reason for Encounter: Painful urination with urinary frequency
Explanation: Laia Nunez is a 24-year-old female presenting with symptoms
suggestive of an acute uncomplicated urinary tract infection (UTI), including
dysuria and increased urinary frequency. The encounter focuses on confirming
diagnosis, ruling out complicated infection or alternative pathology, and initiating
evidence-based treatment to prevent progression.
, REASON FOR ENCOUNTER
Element Description
Encounter Type Acute outpatient evaluation
Chief Complaint Dysuria and urinary frequency
Duration 3 days
Frequency Urinating every 1–2 hours
Associated Symptoms Urgency, suprapubic discomfort
Aggravating Factors Urination
Relieving Factors Hydration provides mild relief
Systemic Symptoms No fever, flank pain, or nausea
Patient Goals Symptom relief and infection treatment
EXPLANATION ON REASON FOR ENCOUNTER
The patient presents for evaluation of urinary symptoms consistent with acute
cystitis. Prompt diagnosis is necessary to confirm infection, exclude pyelonephritis
or sexually transmitted infections, and initiate antimicrobial therapy to prevent
complications such as ascending infection.