SOAP Note: Urinary Incontinence

Sexual History

Partner: Divorced.

Practices: Denies having sexual intercourse with any partner.

Protection: No protective approaches are being used.

Past Hx of STDs: She had several cases of candidiasis.

Prevention of Pregnancy: . Does not use any contraception currently.

Other concerns: She wishes to stop the incontinence.

PF explains HPI as follows:

O- Two months ago.

L- Points at the vulva.

D- Intermittent.

C- Pins.

A- Aggravates on coughing, laughing, or bending.

R- Relieves when she sits down and relaxes her muscles.

T- Symptoms noticed every time the aggravating factors occur.

T-Not on any medications.

S- Symptoms rated 6/10.

Drug Intolerances: Does not confirm any.

Allergies: None to drugs, food, or latex.

Chronic Illness or Trauma: None.

Surgeries and Hospitalizations: Happened once 30 years ago when she had a hip fracture.

Height: 5’ 6.”

· 1- Vaginitis (N76.0): Patients with vaginitis have slight itchiness of the vagina (Schuiling & Likis, 2017). PF has slight itchiness of the vagina, thus suggesting this diagnosis.

· 2- Cystitis without hematuria (N30.00): Increased frequency of urination is an indication of cystitis (Hawkins, Roberto-Nichols, & Stanley-Haney, 2016). PF does not produce blood, thus showing that she could be having cystitis without hematuria.

· 3- Bladder carcinoma (C67.9) Bladder carcinoma often results in increased urination (Clark et al., 2013). The condition is present in this case, thus showing that PF could be having the disease.

Final diagnosis

Stress incontinence (N39.3): The subjective data shows that PF produces urine upon coughing, laughing, or bending. No infection is noted from the objective data. Hawkins et al. (2016) argue that patients with stress incontinence produce urine after straining their muscles. Thus, PF has stress incontinence.

Further testing: Biopsy of the bladder shows that PF is negative for cancerous cells. Further testing of the endometrial tissue reveals no infection. Thus, the possibility of carcinoma or cystitis is ruled out.

Pharmacologic management: PF has been prescribed oxybutynin. She will take 5mg orally daily after every eight hours for seven days. Other medications have been reserved until follow-up.

Non-pharmacologic approach: None.

Education: PF has been taught to delay urination, which can help in retaining urine in the bladder. She has also been taught to urinate every three hours and adhere to the schedule.

Follow-up: PF will return after seven days for assessment of her progress. Other drugs and educational interventions will be made after assessing her response to the current therapy.

Self-Assessment and Clinical Guidelines: The management for this patient is efficient considering that it is the first encounter. PF provided sufficient subjective and objective data, which was used for establishing the diagnosis of stress incontinence. Wilson and Waghel (2016) argue that oxybutynin is an effective drug to manage urinary incontinence. Thus, the use of oxybutynin in this case is beneficial for treating stress incontinence. Additionally, Heron, Grzeda, von Gontard, Wright, & Joinson (2017) argue that bladder control is effective in managing stress incontinence. PF has been taught bladder control strategies, thus she is likely to recover. Wilson and Waghel (2016) recommend other drugs such as tolterodine. This management does not include these drugs, but their use will be determined during the follow-up.