Women’s Health Soap Note: A.J. AGE: 65 Years, GENDER: Female RACE: African-American

Women's Health Soap Note #3

PATIENT INITIALS: A.J. AGE: 65 Years, GENDER: Female RACE: African-American

SUBJECTIVE:

Chief Compliant: The patient complains about a burning sensation while passing urine, constant leakage of urine when they cough, sneeze or laugh and an urge to urinate frequently.

History of Present illness (HPI): AJ is a 65 year-year-old female presenting to the gynecological office complaining of her current condition on frequent urine leakage. The patient reports that this issue started as minor as she approached her sixties but has recently affected her normal functioning since urine leaks. She also reports a slight pain when passing urine and a frequent urge to urinate. She notes that her relationship with her husband has been deteriorating due to her urinary incontinence. They no longer get intimate as they sleep on separate beds since recently, she has been urinating on herself while asleep.

Location: Urinary Tract

Quality: Frequent urine leakages

Timing: mild symptoms started at 60 years, but the condition has worsened in the last three months.

Severity: Urine leaks daily following activities such as laughing, sneezing, and coughing

Setting: The patient reports that she began getting concerned after feeling slight pain while urinating and her inability to control urine while asleep, which started over the last two weeks.

Alleviating and aggravating factors: Urine leakage occurs when the patient is primarily active during the day. The situation worsens when the patient feels the urge to pass urine but cannot wait to get to the toilet in time.

Associated signs and symptoms: The patient complain about passing a small about of urine after a strong urge to urinate and pain while urinating. She identifies that she is stressed due to her condition, which limits her interactions with many people, including her family.

Current medication: The patient explains she is not under any medication for the urinary incontinence condition.

PMH: The patient explains that she has had diabetes ever since she turned 50 years old and has been trying to manage it through medications and a slight lifestyle change. She also reports having a fistula after the third child's birth, which was treated. During her youth days, she did not experience any other major illness. Additionally, last year she received the covid-19 jab and had some adverse effects shortly after, including fever, loss of appetite, and headache, but with time, the symptoms vanished. The patient denies having any surgeries, but due to the surge with diabetes, she was hospitalized three times for one month, three weeks, and two weeks consecutively. The patient also explains that she has a food allergy. She does not take any form of dairy products but has no known drug allergies.

Family History

The patient has been married for the last thirty-five years living with her husband, and has three children. The husband is sixty-eight years old and has enjoyed a considerably healthy life, although he has suffered from pneumonia for some time and other minor illnesses from time to time. The patient's mother is alive, but the father died from a heart attack. The mother is quite old but has no known health issues. The patient has six siblings, four brothers and two sisters. One of the brothers has throat cancer, while one sister exhibits HTN. The rest of the siblings are relatively healthy. The three children aged 35, 32, and 28 are all healthy and never had major health problems except for the last born, who experiences severe toothache.

Social History: The patient lives in an owned five-bedroom house with his husband and two grandchildren. She denies having smoked or used alcohol before. She also explains that she is a people person and has a good relationship with her siblings and close friends. She also opens up about being a leader in the community.

Review of Symptoms:

General: Patient reports having lost weight around 10 pounds. Also explains that she has been having trouble sleeping well, fatigue, and general body weakness.

Integumentary: The patient denies having skin rashes, lesions, and itching but sweats heavily, especially at night. Additionally, she denies having nail discoloration and abnormal growth nails but has, for the last two years, experienced slight hair loss.

HEENT: Head: Denies having a head injury, depression, and constant migraines. Eyes: Denies eye problems, including eye pain, double vision, glaucoma, or blurred vision, and does not wear glasses. Ears: Denies having hearing loss but reports increased wax. Nose: Denies having any issues with epistaxis, drainage, tenderness, inflammation, or nasal congestion. Mouth and Throat: The patient denies having sores in the mouth, throat pain, and lesions. Besides, the patient denies exhibiting any swelling, dysphagia, swollen gum, dryness, or tenderness.

Respiratory: The patient reports that she coughs once in a while.

Cardiovascular: The patient reports being active in her chores but denies having any history of a heart murmur, chest pain, veins, varicose, and edema.

Gastrointestinal: The patient reports decreased appetite but denies any experiences with reflux, bloating, pyrosis, bloating, nausea, vomiting, diarrhea, constipation, epigastric pain, or hemorrhoids. However, the patient reports trying to eat a balanced diet.

Genitourinary: The patient accepts experiencing incontinence, frequency, and urgency alongside suprapubic pain and nocturia.

Musculoskeletal: Patient reports having muscle pain, cramping, and joint pain.

Neurologic: The patient accepts she has been having headaches, weaknesses, and tingling and denies experiencing a stroke, seizures, paresthesia, or tremors.

Psychiatric: Patients agree to experience changes in mood, anxiety, depressive symptoms, insomnia, and nervousness.

Endocrine: The patient agrees to have an intolerance to extreme cold or heat

Allergic: The patient agrees to have a food allergy, particularly dairy products.

OBJECTIVE DATA:

Vital signs: BP: 129/85. Pulse: 63, Wt: 13O lb, BM1 29.3 kg/m, Height 5’6, O2: 99%

Laboratory and Diagnostic Test Results: There were no lab results

Special tests: Tests requested included pelvic examination, urinalysis, and cystoscopy

ASSESSMENT: AJ is a 65-year-old African-American female patient presenting to the clinic for with a chief complaint of a burning sensation while passing urine, constant leakage of urine when they cough, sneeze or laugh and an urge to urinate frequently.

Physical Assessment: 

General: Mrs. A.J. is a 65-year-old African-American male patient who comes to the clinic for his annual physical assessment. Mrs. A.J. appears to be in no acute distress and oriented in time, place, time, and person. Patient is well developed, mildly-obese, well nourished, alert and cooperative.            

Skin: Skin normal color, texture, and turgor with no lesions or eruptions.

HEENT: Head: normocephalic and atraumatic. Normal scalp hair distribution. Eyes: PERRL, EOMI. Fundi normal, vision is grossly intact. Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema noted. Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Ears: External auditory canals and tympanic membranes clear, hearing grossly intact, no pain, no drainage, no abnormalities, and pink. Right TM intact and pearly gray, positive light reflex. Left TM intact and pearly gray, positive light reflex. Whispered words heard on right. Whispered words heard on left. Nose: No nasal discharge. Nasal mucosa moist and pink, septum midline on right. Nasal mucosa moist and pink, septum midline on left. No pain, no drainage, no deviations, moist and pink. No occlusions. No frontal sinus tenderness or maxillary sinus tenderness noted. Mouth & Throat: Oral mucosa moist without ulcerations or lesions, uvula midline. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition. Tongue moist and pink. Uvula is midline and intact. Neck: Neck supple, non-tender without lymphadenopathy, no masses, or thyromegaly. Trachea is midline. Full ROM noted. No tenderness, no lumps. Thyroid smooth without nodules, no goiter.

Cardiovascular: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis, or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits. Capillary refill <2 seconds. Right carotid pulse: 2+, no. Left carotid pulse: 2+, no thrill on palpation noted. Right carotid artery: no bruit. Left carotid artery: no bruit noted.

Respiration: Lungs clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds. Anterior chest wall symmetric, no deformity, or lesions. Posterior chest wall symmetric, no deformity, or lesions noted. Thoracic expansion symmetric. Anterior and posterior chest walls resonant on percussion. No adventitious sounds on auscultation noted.

Abdomen: Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses. Abdomen protuberant, symmetric, no visible masses or lesions, coarse hair from pubis to umbilicus. No masses, guarding or rebound noted on all quadrants.

Musculoskeletal: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait.

Female Genitalia: No rashes, lesions, or parasites noted in genital area. Palpated inguinal and femoral lymph nodes noted no edema or masses noted. Femoral pulses are strong (2+ symmetrically). No inflammation, rashes, lesions, or vaginal discharge noted. 

Rectal exam: No inflammation, drainage, rashes, lesion, tears or fissures noted to external anus area. The prostate is smooth and intact. No drainage, or objects noted in rectum. Rectal wall palpated no lumps or masses noted. 

Extremities: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities. Strength: 5/5.

Lower extremity: Normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity; examination of both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity. Strength: 5/5.

Neurological: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal.

Psychiatric: Patient is oriented to person, place, and time. Pt. demonstrates good judgment and reason, without hallucinations, abnormal affect, or abnormal behaviors during the examination. Patient is not suicidal.

Diagnosis: 

Stress incontinence N39. 3- This condition causes urine to leak once an individual; exerts pressure on their bladder through coughing, sneezing, or laughing (Yang et al., 2021)

Differential Diagnosis

Atrophic urethritis N34.2- this is a urinary tract issue characterized by frequent urination, itching around the genitals, and pain when passing urine.

Chronic Bacteriuria R82. 71- This condition occurs when bacteria are present in urine and commonly affects pregnant women. Primary symptoms include frequent urination and pelvic pain (Weber-Rajek et al., 2019).

Urinary Tract Infection (UTI) N39. 0 - This common urinary infection among women affects the kidneys, bladder, and urethra. Significant symptoms include urination, abdomen pain, and frequent urination.

ORDER CUSTOM-WRITTEN NURSING SOAP NOTES HERE

PLAN OF CARE

Medications

-Anticholinergics (oxybutynin) 6 mg x2 daily or until satisfactory control is achieved. This medicine will begin by calming the overactive bladder (Zhang et al., 2022).

-The Myrbetriq 25 mg PO qDay to relax the bladder muscle and reduce the frequent urge to urinate.

Education

-Encourage the patient to adopt a proper weight loss plan and emphasize the importance of exercising towards strengthening the pelvic muscle (Virtuoso et al., 2019)

-Advise the patient to avoid other drinks and stick to water only.

-Advise the patient to eat a balanced diet to avoid constipation.

-The patient advised was educated about the side effects such as dry mouth, dry eyes, constipation, urinary retention, blurred vision and increased heart rate, and was encouraged to report any central effects such as dizziness, sedation, confusion and delirium.

-Advice the patient to avoid lifting heavy objects to prevent incontinence.

Follow-up. The patient should return to the clinic after three weeks to assess the progress.

References

Virtuoso, J. F., Menezes, E. C., & Mazo, G. Z. (2019). Effect of weight training with pelvic floor muscle training in elderly women with urinary incontinence. Research quarterly for exercise and sport, 90(2), 141-150.

Weber-Rajek, M., Radzimińska, A., Strączyńska, A., Strojek, K., Piekorz, Z., Kozakiewicz, M., & Styczyńska, H. (2019). A randomized-controlled trial pilot study examining the effect of pelvic floor muscle training on the irisin concentration in overweight or obese elderly women with stress urinary incontinence. BioMed research international, 2019.

Yang, N., Ge, X., Ye, J., Liu, Q., Wu, Y., Yan, H., & Han, X. (2021). Efficacy of acupuncture for urinary incontinence in middle-aged and elderly women: a systematic review and meta-analysis of randomized controlled trials. European Journal of Obstetrics & Gynecology and Reproductive Biology, 257, 138-143.

Zhang, D., Gao, L., Jia, Y., Wang, S., Wang, H., Sun, X., & Wang, J. (2022). Construction of Progress Prediction Model of Urinary Incontinence in Elderly Women: Protocol for a Multi-Center, Prospective Cohort Study. International Journal of Environmental Research and Public Health, 19(2), 734.