Case Study on Urinary Leakage

Case Study: Urinary Leakage

Case Study on 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?

2. What are you considering for her?

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, 1stdegree 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?

Questions for the case study are highlighted below and you are to provide a differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.

Define what you believe is the most important diagnosis any why. Be sure to include the priority in conducting your assessment.

Use the focused SOAP NOTE template and focus on what is being asked of you as highlighted below.  Don’t forget for an episodic visit, there is NOT to be a full PE.  Focus on the systems that correlate to your Chief Complaint.

• Differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.
• Define what you believe is the most important diagnosis. Be sure to include the first priority in conducting your assessment.
• Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.