History of Present Illness (HPI) Template for Dysuria
A comprehensive HPI for dysuria should include specific questions about pain characteristics, urinary symptoms, associated symptoms, and risk factors to guide diagnosis and treatment decisions.
Chief Complaint
- Pain or burning during urination (dysuria)
Pain Characteristics
- Onset and duration of dysuria
- Location of pain (urethral, vaginal, suprapubic)
- Character of pain (burning, sharp, dull)
- Timing of pain (beginning, during, or end of urination)
- Severity (on a scale of 1-10)
- Alleviating and exacerbating factors
Associated Urinary Symptoms
- Urinary frequency
- Urgency
- Nocturia
- Hematuria (visible or microscopic)
- Changes in urine appearance (cloudy, foul-smelling)
- Incomplete emptying sensation
- Hesitancy or straining to void
- Suprapubic or flank pain
- Incontinence
Sexual History
- Recent sexual activity
- New sexual partners
- Use of contraceptives or barrier methods
- History of sexually transmitted infections
- Vaginal discharge (for females)
- Urethral discharge (for males)
Medical History
- Previous urinary tract infections
- Recent urologic procedures or catheterization
- Kidney stones
- Prostate issues (for males)
- Gynecological conditions (for females)
- Neurological disorders affecting bladder function
- Immunocompromised status
Medication History
- Current medications
- Recent antibiotic use
- Use of spermicides or vaginal products
- Use of potential bladder irritants (caffeine, alcohol, spicy foods)
Risk Factors Assessment
- Diabetes
- Pregnancy status (for females)
- Menopause status and hormone replacement therapy (for females)
- Anatomical abnormalities of the urinary tract
- Urinary retention or incomplete emptying
- Catheter use
- Recent instrumentation of urinary tract
- Immobility
Review of Systems
- Fever, chills
- Nausea, vomiting
- Flank pain
- Vaginal symptoms (discharge, odor, irritation)
- Penile or testicular symptoms
- Lower back pain
- Joint pain (possible reactive arthritis)
- Skin rashes or lesions
Hydration and Voiding Habits
- Daily fluid intake
- Frequency of urination
- Recent changes in voiding patterns
- History of urinary continence
Impact on Quality of Life
- Sleep disturbances due to symptoms
- Effect on daily activities
- Effect on sexual function
This structured HPI template covers the essential elements needed to evaluate a patient with dysuria, allowing for appropriate diagnosis and management planning 1, 2, 3. The information gathered will help differentiate between infectious and non-infectious causes, guide laboratory testing, and inform treatment decisions.