Hillary is a 63-year-old woman G7P7 all uncomplicated NSVDs, complains of inadvertently urinating on herself whenever she coughs, sneezes, or heartily

Table 1

Hillary is a 63-year-old woman G7P7 all uncomplicated NSVDs, complains of inadvertently urinating on herself whenever she coughs, sneezes, or heartily laughs. It has been happening intermittently

Testing or Management

Define and describe

Candidates eligible for this include:

Special consideration

Example: Urinalysis and Urine culture

Lab tests to assess and rule out UTI

Performed on all patients who are having urinary symptoms especially, dysuria, urinary frequency, urgency, and urinary incontinence

n/a

Urodynamics

Pelvic Floor Muscle Therapy

Percutaneous Tibia Nerve Stimulator

Pessary Therapy

Surgical management

Type of incontinence

Definition and Example

How to assess Treatment/ Management

Stress Incontinence

Urge Incontinence

Nocturnal Incontinence

Transient Incontinence

since the birth of her last 3 children, but it now happens so often that she must wear a sanitary pad, and she is afraid there can be an odor at times. She now also feels “something at the entrance.” Upon physical exam, you note that there is an organ about 1cm covering at the 12 o’clock of her vaginal entrance. She asks you what, if anything, can be done to alleviate this that does not have to entail having surgery.

Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.

1. Subjective: a. What other relevant questions should you ask regarding the HPI? b. What other medical history questions should you ask? c. What other social history questions should you ask? d. What other family history questions should you ask?

2. Objective: a. Write a detailed focused physical assessment on this patient. b. Explain what test(s) you will order and perform, and discuss your rationale for

ordering and performing each test. 3. Assessment/ Diagnosis:

a. What is your presumptive diagnosis? Why? b. Any other diagnosis or differential diagnosis you would like to add? c. What type of incontinence is this patient experiencing?

4. Plan: a. How will you manage this patient? What treatment or medication would you prescribe

and why? b. Explain treatment/management guidelines including any possible side effects and/or

consideration management of the diagnosis. c. What patient education is important to include for this patient? (Consider including

pharmacological, supplements, and non pharmacological recommendations and education)

d. What is the follow-up plan of care?

SOAP NOTE FORMAT

Subjective

CC:

HPI:

Medications:

Allergies:

LMP:

Gyn/OB history:

PMH:

Chronic Illness/ Major trauma:

Family Hx:

Social Hx:

ROS

– List the body systems and provide answers

– (Don’t forget to include Gyn ROS)

– You can include questions here that you’d like to ask the patient

Objective Data

General- provide findings

VS

List body systems- provide findings

– (Don’t forget Gyn System)

– (You can include answers here to questions posed in the prompt)

Include POCT (Point of Care testing) not labs that you will send to the laboratoryAssessment/

DiagnosisInclude the ICD10 code

DDX

Plan

Diagnostic tests

Lab Tests

Treatment

Medication

Referrals

Education

Health Maintenance

Follow up

Prompt Questions

(You can include answers here that is asked in the prompt)