Case Study: Mable Albright 48 Urinary Leakage SOAP NOTE

Case Week Eight 

Please include ICD codes with Diagnosis and rationales for differential diagnosis. Please list 1 Primary Diagnosis & 3 differential. 

Case Study: Urinary Leakage

Mable Albright is a 48-year-old, native American who presents to your clinic with the complaint of urinary leakage. She relates this has been worsening over the past 2 years.  She now must wear a pad all the time and states it is interfering with her work as she is going to the bathroom all the time.  Medical history is negative, surgical history is remarkable for wisdom teeth and a bilateral tubal ligation.

VSS: and normal

5’0 172 lbs. (BMI 33.6) T 98 P 70 R18 02Sat 98%

QUESTIONS:

1. What questions do you have for Mable? Please include questions that need to be asked?
2. What are you considering for her? Answer this question also please. 

UPDATE:

Mable relates she leaks when she coughs or laughs and sometimes can’t get her pants down before her urine stream starts when she goes to the bathroom.  When she leaks, she states she will soak thru her underwear and pants. Occasionally, the urine will run down her legs.

Mable has had 5 pregnancies she delivered at term. The first was an 8 lb. 10oz delivered by forceps, the next three were spontaneous and they weighed between 6 and 8 and ½ pounds, and her last was a 10 lb. baby for which she had a shoulder dystocia and “tore a lot”.

Mable relates that sometimes after cleaning her house or standing all day, she feels a lot of pressure, but it goes away when she sits down. All her symptoms have been present since her last delivery 9 years ago, but they have been getting worse.

You have Mable complete a voiding diary which shows that she drinks approximately 84 ounces of fluid through the day and voids about every 3-4 hours during the day. Her leaking has occurred when she first gets home from work.

 

Physical exam:

• VVBSU, parous, vagina somewhat gaping, 1st degree cystocele
• Cervix parous, wnl
• Uterus: anteverted, 10 cm, non-tender
• Adnexa: without masses or tenderness

Urine culture and urinalysis-PENDING

QUESTION:

What is your differential diagnosis?

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Episodic/Focused SOAP Note Template

Patient Information:

Initials: Mable Albrigh; Age: 48 years, Sex: Female, Race: Native American

S.

CC (chief complaint): “Urinary leakage.”

HPI:

M.A. is a 48-year-old, Native American who presents to the clinic with a complaint of urinary leakage. She states that the urinary leakage has increasingly worsened over the past two years. She is forced to wear a pad all the time. She reports that the urinary leakage interferes with her work as she keeps going to the bathroom all the time.

Current Medications: None.

Allergies: None

PMHx: Immunization is current. No chronic illnesses.

Soc& Substance Hx: M.A. is an auditor. She is married and has two children 24 and 19 years. Her hobbies are baking and traveling. She reports taking 2-3 glasses of wine on weekends but denies smoking or using illicit substances.

Fam Hx: No family history of chronic illnesses.

Surgical Hx: Surgical history is remarkable for wisdom teeth extraction and bilateral tubal ligation.

 

Mental Hx: None.

Violence Hx: No history of domestic violence.

Reproductive Hx: LMP-2 weeks ago. No history of menstrual disorders. Para 2+0. Currently on IUD. She is homosexual.

ROS:

GENERAL: Denies weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: Denies visual changes, blurred/double vision, hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: Denies rash or itching.

CARDIOVASCULAR: Denies chest pain, palpitations, or edema.

RESPIRATORY: Denies shortness of breath, cough, or sputum.

GASTROINTESTINAL: Denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

NEUROLOGICAL: Positive for lack of bladder control. Denies headache, dizziness, syncope, paralysis, or tingling in the extremities.

MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: Denies anemia, bleeding, or bruising.

LYMPHATICS: Negative for enlarged nodes.

PSYCHIATRIC: Denies a history of depression or anxiety.

ENDOCRINOLOGIC: Denies excessive sweating, cold/heat intolerance, polyuria, or polydipsia.

GENITOURINARY/REPRODUCTIVE: Reports urinary leakage. Denies dysuria, abnormal PV discharge, breast tenderness, lumps, or nipple discharge.

ALLERGIES: Denies, hives, eczema, or rhinitis.

O.

Physical exam:

Vital signs: BP-120/80; HR-78; RR-16; Temp-98.4

Height- 5’0; Weight-172 lbs.; BMI-33.6

Neurologic: CNs are intact. Muscle strength- 5/5. Perineal reflexes are present.

GENITOURINARY: Normal female genitalia. Pad test-Positive

Diagnostic results: No tests were ordered.

A.

Primary and Differential Diagnoses

Urinary Incontinence:  This is characterized by an involuntary loss of urine severe enough to cause social or hygienic problems (O’Connor et al., 2021). The patient reports urinary leakage that forces her to wear a pad. The leakage interferes with her occupational functioning. This makes Urinary incontinence the priority diagnosis for this patient.

Overactive bladder (OAB): The hallmark symptom of OAB is urinary urgency. Some patients may experience urgency urinary incontinence (Scarneciu et al., 2021). Urinary frequency and nocturia are usually present. The patient has urinary incontinence making OAB a differential diagnosis.

Bladder Dysfunction: This is a complication of chronic low back pain. Bladder dysfunction is characterized by urinary incontinence, hesitancy, dysuria, urgency, frequency, recurrent urinary tract infections (UTIs), and nocturia (Hughes & May, 2020).  This is a differential diagnosis based on the patient’s urinary leakage, which forces her to frequently visit the bathroom.

P.

Diagnostic Studies: Diagnostic tests that should be ordered include urinalysis and urine culture to rule out UTI.

Kidney function studies like Blood urea nitrogen (BUN) and creatinine are important to rule out kidney failure (Sharma & Chakrabarti, 2018).

Electromyography (EMG) is essential to establish whether the patient’s voiding is coordinated or uncoordinated (Sharma & Chakrabarti, 2018).

A voiding cystourethrogram (VCUG) may be ordered to examine the size, shape, support, and function of the urinary bladder (Sharma & Chakrabarti, 2018).

Treatment Options:

1. Anticholinergic agents: Propantheline bromide 30 mg every 6 hours.

Anticholinergics are used in Urinary incontinence because they increase bladder capacity, increase the volume threshold for initiation of an involuntary contraction,  and reduce the strength of involuntary bladder contractions (O’Connor et al., 2021).

1. Antispasmodic agents: Trospium (Sanctura) 20 mg twice daily.

Trospim has antispasmodic and antimuscarinic effects and is indicated to treat urinary incontinence, urgency, and frequency (McKinney et al., 2022).

 

3. Tricyclic antidepressants (TCAs): Imipramine 50 mg OD.

Imipramine facilitates urine storage by reducing bladder contractility while increasing outlet resistance (O’Connor et al., 2021).

Non-pharmacological Interventions

1. Pelvic floor (Kegel) exercise therapy: To strengthen pelvic floor muscles.
2. Use of anti-incontinence devices (McKinney et al., 2022).
3. Nutrition therapy for weight reduction. This is helpful for obese patients since stress incontinence is worsened by increased abdominal pressure from obesity (Yazdany et al., 2020).

Referral: Urology consultation.

Follow-up: Schedule follow-up after two weeks.

 

Reflection: The assignment enlightened me about urinary incontinence. I have realized that many individuals suffer in silence from this condition and are socially isolated. In a different situation, I would detail the symptoms of urinary incontinence including leakage, frequency, urgency, and nocturia. I would also obtain a 24-hour intake and output record or a voiding diary. Health promotion should focus on weight loss since obesity has been identified as a risk factor for the development of urinary incontinence (Yazdany et al., 2020). Thus, interventions to manage obesity can result in improved continence

 

 

References

Hughes, C., & May, S. (2020). A directional preference approach for chronic pelvic pain, bladder dysfunction, and concurrent musculoskeletal symptoms: a case series. The Journal of Manual & manipulative therapy, 28(3), 170–180. https://doi.org/10.1080/10669817.2019.1668994

McKinney, J. L., Keyser, L. E., Pulliam, S. J., & Ferzandi, T. R. (2022). Female Urinary Incontinence Evidence-Based Treatment Pathway: An Infographic for Shared Decision-Making. Journal of Women’s Health (2002), 31(3), 341–346. https://doi.org/10.1089/jwh.2021.0266

O’Connor, E., Nic An Riogh, A., Karavitakis, M., Monagas, S., & Nambiar, A. (2021). Diagnosis and Non-Surgical Management of Urinary Incontinence – A Literature Review with Recommendations for Practice. International Journal of general medicine, 14, 4555–4565. https://doi.org/10.2147/IJGM.S289314

Scarneciu, I., Lupu, S., Bratu, O. G., Teodorescu, A., Maxim, L. S., Brinza, A., Laculiceanu, A. G., Rotaru, R. M., Lupu, A. M., & Scarneciu, C. C. (2021). Overactive bladder: A review and update. Experimental and therapeutic medicine, 22(6), 1444. https://doi.org/10.3892/etm.2021.10879

Sharma, N., & Chakrabarti, S. (2018). Clinical Evaluation of Urinary Incontinence. Journal of mid-life health, 9(2), 55–64. https://doi.org/10.4103/jmh.JMH_122_17

Yazdany, T., Jakus-Waldman, S., Jeppson, P. C., Schimpf, M. O., Yurteri-Kaplan, L. A., Ferzandi, T. R., Weber-LeBrun, E., Knoepp, L., Mamik, M., Viswanathan, M., Ward, R. M., & American Urogynecologic Society (2020). American Urogynecologic Society Systematic Review: The Impact of Weight Loss Intervention on Lower Urinary Tract Symptoms and Urinary Incontinence in Overweight and Obese Women. Female pelvic medicine & reconstructive surgery, 26(1), 16–29. https://doi.org/10.1097/SPV.0000000000000802