|Name: PF||Pt. Encounter Number|
|Date: 11/8/2017||Age: 67||Sex: Female|
|CC: “I urinate every time I cough or laugh. I am embarrassed, but I need treatment.”|
|HPI: PF has been in good health since her youth. However, two months ago, she noticed unusual excretion of urine upon coughing and laughing. She thought it was a usual problem that would end with time. However, the problem has persisted. Currently, she excretes urine even when she bends or walks faster. She needs treatment since the problem is causing embarrassment in public.
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.
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.
|Medications: Not using drugs currently.|
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.
|Family History: Both her parents died, but they never had any genetic diseases. No history of chronic illness is known about the parents or the entire family.|
|Social History: She got divorced at the age of 30. She has four children, who are all alive and well. She does not abuse any illicit drugs. She does not drink alcohol, but she smokes occasionally.|
|General: Denies varying energy levels, chills, night sweats, or weight changes.||Cardiovascular: Denies PND, orthopnea, palpitations, or edema.|
|Skin: Denies any discolorations, easy bleeding, or delayed healing of wounds.||Respiratory: Denies hx of pneumonia, hemoptysis, TB, or dyspnea.|
|Eyes: Denies the use of glasses, experiences of blurry vision, or eye pain.||Gastrointestinal: Denies constipation, upper abdominal pain, or hepatitis.|
|Ears: Denies ringing in ears, ear pain, or hearing loss.||Genitourinary: Menarche happened at 13 years. Pap was done one year ago, and results were negative. No mammogram has ever been done. Positive for slight dysuria and itchiness of vaginal introitus. Denies lower abdominal pain or vaginal bleeding.|
|Nose/Mouth/Throat: Denies epistaxis, sinus problems, or lesions in the mouth.||Musculoskeletal: Denies back pains, osteoporosis, fractures, or joint swellings.|
|Breast: Denies bumps or dimpling.||Neurological: Denies scotoma, transient paralysis, syncope, or black out spells.|
|Heme/Lymph/Endo: HIV negative. Never undergone blood transfusion. Denies goiter or lethargy.||Psychiatric: Denies insomnia or any experiences of suicidal ideations.|
|Weight: 145 lbs BMI: 23.4
Height: 5’ 6.”
|Resp: 20 bpm||BP: 120/78mmHg|
|Temperature: 100.4 F||Pulse: 82 bpm
|General Appearance: Oriented but sick-looking.|
|Skin: Dry, brown, and warm. No growths, rashes, or lesions.|
|HEENT: Normocephalic without lesions. Atraumatic. Ears: Visible landmarks and patent canals. Eyes: Pupils respond to light. No scleral injection. Neck: No occipital nodes or cervical lyphadenopathy. Full ROM and supple. Nose, Mouth, and Throat: Throat not inflamed. 30 teeth in good repair. No abnormalities in the nostrils.|
|Cardiovascular: S1 and S2 sounds heard. No murmurs. Regular heart rhythm. No edema.|
|Respiratory: Clear lungs and easy respirations.|
|Gastrointestinal: Upper abdomen not soft. Non tender abdomen. Active BS. No organomegaly.|
|Breast: Free from growths, masses, or discharge.|
|Genitourinary: Pink vaginal canal. Urinary meatus not inflamed. Symmetrical labia with normal vulva. No blood from the vagina. Clear discharge from the vagina. Urine comes out of the urinary meatus as she coughs.|
|Musculoskeletal: No fractures. Full ROM.|
|Neurological: Erect posture with a stable balance. Speaks with a shaky voice.|
|Psychiatric: Fully oriented. Answers questions as asked. Kempt.|
|Lab Tests: Urinalysis reveals no infectious agents in the urine.|
|Special Tests: None.|
| Differential Diagnoses
· 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.
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.