1. Lynne Episodic/Focused SOAP Note Patient Information: M.A, 48 years old, Female, Native American S. CC: “Urinary leakage” HPI: M.A. is a 48-year-old Native American female who presents to the clinic today with complaints of urinary leakage. She states it started two years ago and has worsened, causing her to wear a pad all day. She struggles with work due to using the restroom frequently throughout the day. She denies any burning while urinating, abdominal pain, or fevers. She denies any contributing or exacerbating factors. Current Medications: Tylenol 650 mg 1 tab every 4-6 hours prn pain. Allergies: No known drug allergies. PMHx: Tdap 2022, Influenza 10/2023, Covid 2/2022 & 3/2022. No past medical history. Soc & Substance Hx: Works full-time as a teacher. She has been married for 20 years and has two teenage sons who live at home. Hobbies include exercising, book clubs, and bingo. She is a non-smoker and denies any vaping or illicit drug abuse. She drinks 2-3 glasses of wine once a week. She drinks 2 cups of coffee daily. She wears a seatbelt when in a motor vehicle and refrains from texting and driving. Fam Hx: Mother is 75 years old with a history of thyroid disease. The father is 78 years old with hypertension and chronic kidney disease history. She is an only child. Her maternal and paternal grandparents are deceased. Surgical Hx: Wisdom teeth extraction 2015, bilateral tubal ligation 2008. Mental Hx: Denies any history of mental illnesses. No history of self-harm or suicidal ideations. Violence Hx: Denies any concerns or issues with safety at home or within the community. Reproductive Hx: LMP 10/5/23, G2P2A0L2. Contraceptive: tubal ligation. Heterosexual, monogamous. Denies any sexual concerns. contraceptive use (method ROS: GENERAL: Denies weight loss, fever, chills, weakness, or fatigue. HEENT: Head: Pt denies headaches, dizziness, or pain. Eyes: Pt denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: Pt denies discharge or ear pain. Denies history of chronic ear infections or foreign objects in ears. Denies vertigo. Denies nasal drainage or recent sore throats. SKIN: Denies any rash or lesions. CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema. RESPIRATORY: Denies shortness of breath, cough, or sputum. GASTROINTESTINAL: Pt denies abdominal pain. Denies any nausea or vomiting. Denies changes in bowel pattern or blood in stool. NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain, or stiffness. HEMATOLOGIC: Denies anemia, bleeding, or bruising. LYMPHATICS: Denies enlarged nodes—no history of splenectomy. PSYCHIATRIC: Denies any history of depression or anxiety. ENDOCRINOLOGIC: Denies sweating or cold or heat intolerance: no polyuria or polydipsia. GENITOURINARY/REPRODUCTIVE: Denies burning on urination. LMP: 10/5/2023. Denies any breast lumps, pain, or discharge. Denies vaginal discharge. Is sexually active. Reports daily and constant urinary incontinence. O. General: M.A. is sitting upright on the exam table, alert and oriented. Well-spoken and answers questions appropriately. Vitals: BP 136/78, HR 75, R 20, T 98.6, Po2 100% on RA, HT 5’, WT 172 lbs (BMI 33.6). CARDIOVASCULAR: S1, S2, no murmur, rub, or gallup. No JVD. RESPIRATORY: Bilateral lung sounds clear to auscultation, normal respiratory effort without use of accessory muscles. GENITOURINARY/REPRODUCTIVE: No CVA tenderness. External genitalia: hair distribution of normal female pattern. No vulvar erythema or lesions. Vagina: walls pink, moist, rugae present. Grade 1 prolapse noted. Cervix: without lesions, discharge, or bleeding noted. Uterus: unable to view due to body habitus; Adnexa: unable to view due to body habitus. Diagnostic results: Urinalysis: unremarkable. Vaginal/pelvic exam: performed to view the external and internal anatomy of the genital tract. A. Urinary Incontinence (UI) is described as an involuntary loss of urine. “Urinary incontinence is a common problem among women worldwide, resulting in substantial economic burden and decreased quality of life” (Hu et al., 2019). UI is classified as transient or chronic. “Transient UI arises suddenly, lasts less than six months, and can be reversed if the underlying cause is addressed” (Hu et al., 2019). Chronic UI is characterized by several subtypes: stress, urge, mixed, overflow, or functional incontinence. Vaginal deliveries, increased age, parity, obesity, history of hysterectomy, diuretic use, high-impact exercise, poor overall health, and increased medical comorbidity are risk factors associated with urinary incontinence. A thorough screening should be performed to determine what type of UI she has; however, based on her current symptoms, I would diagnose her with mixed urinary incontinence. Cystocele: also called bladder prolapse, occurs when the bladder descends into the vagina due to weakened supporting structures. Patients may experience vaginal bulging when symptoms are more severe. “Other symptoms include urgency, frequency, urge incontinence, recurrent urinary tract infections, back pain, renal failure, staghorn calculi, and urinary retention” (Lalwani et al., 2023). If left untreated, cystocele can become a chronic problem affecting a woman’s well-being, mental status, and sexual health. Depending on the severity of the prolapse, treatment is either pelvic muscle exercises or vaginal pessaries. Patients often benefit from pelvic floor therapy with someone specializing in pelvic floor exercises. Although my first choice of diagnosis is urinary incontinence, her grade 1 prolapse is also a contributing factor. Atrophic vaginitis is a symptomatic inflammatory process that occurs after menopause, causing distressing vaginal and urinary symptoms. “Genitourinary syndrome of menopause, a group of chronic, progressive, hypoestrogenic conditions, includes vulvovaginal atrophy, atrophic vaginitis, and bladder and urethral dysfunctions” (Flores et al., 2022). Symptoms include vulvovaginal dryness due to lack of estrogen, recurrent urinary tract infections, urethral pain, hematuria, and urinary incontinence. M.A. is not postmenopausal at this time and continues to have monthly periods, so I would rule this out as a primary diagnosis. Plan: Start Oxybutynin 5 mg take one tablet by mouth twice daily. Encourage weight loss, caffeine reduction, fluid management, and reduce constipation. Avoid straining during bowel movements, as this can further weaken pelvic floor muscles. Bladder training: timed voiding. Refrain from delaying voiding. Encourage kegel exercises several times daily. Refer the patient to pelvic floor therapy. Follow-up in 6 weeks Reflection Researching this case study was very personal to me as these were symptoms I experienced myself due to childbirth. These symptoms can affect women emotionally causing a-lot of distress and embarrassment. Other treatments available for women experiencing urinary incontinence and bladder prolapse are electrical stimulation and dry needling. References Flores, S.A., & Hall, C.A. (2022). Atrophic Vaginitis. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK564341/Links to an external site. Hu, S.J., & Pierre, F.E. (2019). Urinary Incontinence in Women: Evaluation and Management. American Family Physician, 100(6). https://www.aafp.org/pubs/afp/issues/2019/0915/p339.pdfLinks to an external site. Lalwani, N., & Menias, C.O. (2023). Cystocele. ScienceDirect. https://www.sciencedirect.com/topics/medicine-and-dentistry/cystocele 2. Sabrina Initial Post: Patient Information: BB, 39, F, Black S. CC (chief complaint): breast tenderness, fatigue, and nausea HPI: Bonita Bubble is a 39-year-old female presenting today at the clinic with a positive home pregnancy test. Her medical history is negative. Surgical history is remarkable for a c section. Gyn history 1st menses age 12, with cycles coming every 28 days and lasting for 5 days. Her pap and std history are negative. She has been taking vitamins for the past 6 years. She is complaining of breast tenderness, fatigue, and nausea. Location: breast Onset: 3 days ago Character: tenderness Associated signs and symptoms: nausea and fatigue Timing: during the day and night Exacerbating/relieving factors: when touched. None. Severity: 6/10 pain scale Current Medications: Multivitamin 1 po daily. Last taken today at 1000. Allergies: NKDA Known environmental or food allergies. PMHx: Immunization status/schedule up to date. Soc & Substance Hx: Information needed. Not Provided. Fam Hx: Information not included. Surgical Hx: C-Section in 2017. Mental Hx: No history of depression or anxiety. Denies SI/HI Violence Hx: No safety concerns noted at home or within the community. Reproductive Hx: [LMP],07-15-23. G6P3. Not nursing/lactating. No contraceptive use. Types of intercourse information not provided. Heterosexual. No sexual concerns. ROS: GENERAL: No weight loss, fever, chills, weakness. Complaints of fatigue. HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema. Breast tenderness noted. RESPIRATORY: No shortness of breath, cough, or sputum. GASTROINTESTINAL: nausea noted. No vomiting, or diarrhea. No abdominal pain or blood. NEUROLOGICAL: Reports of fatigue. No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: Breast tenderness noted. No muscle pain, back pain, joint pain, or stiffness. HEMATOLOGIC: No anemia, bleeding, or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia. GENITOURINARY/REPRODUCTIVE: Pregnant. LMP: 07-15-23. Breast tenderness. No discharge. No reports of vaginal discharge, or pain. Yes, sexually active. Reports start of Menses’ at age 12. ALLERGIES: No history of asthma, hives, eczema, or rhinitis. O. Height 5’ 2” Weight 140 (BMI 25.6), BP 120/60 P 70 HEENT: Head: normocephalic, no lesions. EYES; PERRLA EOM’s full, conjunctivae clear. TM intact. Nose: Mucosa normal and Neck: lymph nodes grossly normal. No masses. Lungs/CV: Chest is clear to auscultation bilaterally, normal respiration, rhythm, and depth upon exam Breast: Bil Breast tenderness. Abd: bowel sounds X 4 quadrants. VVBSU: WNL Cervix: firm, smooth, scant white discharge Uterus: RV, mobile, non-tender Adnexa: intact without discomfort. No tenderness Diagnostic results: HCG test – to confirm pregnancy. According to Cole et al. (2018). Human chorionic gonadotropin (hCG) measurement is the basis of all pregnancy tests. Ultrasound – to rule out ectopic pregnancy and visualize inflammation of the gallbladder. According to According to MOU et al. (2019). An abdominal ultrasound is the test commonly used to look for gallstones. CBC/CMP – to detect electrolyte imbalances. CT Scan – to visualize inflammation of the appendix According to Jones et al. (2019). CT images are the best way to accurately diagnose inflammation of the appendix. Doppler ultrasound to hear fetal heart tones. Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines). A. Primary: Pregnancy Pregnancy lasts about 40 weeks, counting from the first day of your last normal period. The weeks are grouped in three trimesters. According to Cole et al. (2018). Human chorionic gonadotropin (HCG) measurement is the basis of all pregnancy tests. HCG is produced by trophoblast cells of the placenta in pregnancy. In the week following missing menses, hyperglycosylated (HCG) measurements may be more sensitive than regular HCG measurements in detecting pregnancy. Symptoms of pregnancy breast changes, fatigue, frequent urination, nausea, vomiting, missed period, morning sickness, food cravings, backache, and breathlessness. Differentials: Ectopic Pregnancy According to Hendriks, E., Rosenberg, R., & Prine, L. (2020). Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. Risk factors include a history of pelvic inflammatory disease, cigarette smoking, fallopian tube surgery, previous ectopic pregnancy, and infertility. The definitive diagnosis of ectopic pregnancy can be made with ultrasound visualization of a yolk sac and/or embryo in the adnexa. Symptoms include abdominal or pelvic pain, bloating, nausea, vomiting, vaginal bleeding, or cramping. Cholecystitis Cholecystitis is inflammation of the gallbladder, a small, digestive organ beneath the liver. It is often caused by stones that block the tube leading from the gallbladder to the small intestine. According to MOU et al. (2019). The prevalence of gallstones is reported to range between 10% and 15% among adults, making it one of the most common gastroenterological conditions. Symptoms include abdominal pain, nausea, vomiting, fever, and clay-colored stools. Appendicitis The appendix is a pouch on the colon that has no little-known purpose in the past. Appendicitis is a condition in which the appendix becomes inflamed and filled with pus causing abdominal pain. According to Jones, M. W., Lopez, R. A., & Deppen, J. G. (2018). Today the appendix is accepted that this organ may have an immunoprotective function and acts as a lymphoid organ, especially in the younger person. Appendicitis occurs most often between the ages of 5 and 45, with a mean age of 28. Symptoms consist of abdominal pain in the lower right quadrant, nausea, vomiting, fever, urinary frequency, and anorexia. Plan: Administer Pregnancy test. Refer to OB/GYN Follow up in one month. Educate patient on safe sex practices Educate on diet and medications References Cole, L. A., Khanlian, S. A., Sutton, J. M., Davies, S., & Stephens, N. D. (2018). Hyperglycosylated hCG (invasive trophoblast antigen, ITA) a key antigen for early pregnancy detection. Clinical biochemistry, 36(8), 647-655. Hendriks, E., Rosenberg, R., & Prine, L. (2020). Ectopic pregnancy: diagnosis and management. American family physician, 101(10), 599-606. Jones, M. W., Lopez, R. A., & Deppen, J. G. (2018). Appendicitis. Mou, D., Tesfasilassie, T., Hirji, S., & Ashley, S. W. (2019). Advances in the management of acute cholecystitis. Annals of gastroenterological surgery, 3(3), 247-253. Assignment: Respond to the above post. Each post should include 2 references. Each reference should be no older than 5yrs.
