Nursing
Based on your assigned case study, post the following:
Provide a 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.
please use episodic soap note format see attached
ANSWER
Episodic/Focused SOAP Note Template
Patient Information:
MA, 48, female, Race
S.
CC (chief complaint): Mable Albright visits the clinic complaining of urinal leakage.
HPI: MA, a 48 year old Native American female states that when she laughs or coughs she has to go to the bathroom before her urine starts to stream. The urinal leakage has been worsening over the past 2 years which has forced her to wear pads all the time.
Location: Bladder
Onset: 2 years ago
Character: Urinary leakage
Associated signs and symptoms: Coughing, a lot of pressure
Timing: Occurs after laughing or coughing
Exacerbating/relieving factors: pressure relieves after sitting down, uses pads to prevent soaking her pants.
Severity: 7/10 pain scale
Current Medications: No current medications
Allergies: No known allergies
PMHx: A surgical history for wisdom teeth and a bilateral tubal ligation. MA has urinary leakage whose symptoms began since her last delivery 9 years ago but the symptoms have been getting worse for the last two years.
Soc & Substance Hx: No pertinent data about her social and substance history.
Fam Hx: Unknown
Surgical Hx: A surgical history for wisdom teeth and a bilateral tubal ligation.
Mental Hx: No mental history
Violence Hx: No violence history
Reproductive Hx: MA has had 5 pregnancies. The first was 8 lb.10oz delivered by forceps, the other three were natural and they weighed between 6 and 8 and ½ pounds, and her last was a 10 lb. baby for who had a shoulder dystocia and “tore a lot”.
ROS:
GENERAL: MA complains of urinary leakage. No chills, fevers, weight loss, weakness or fatigue.
HEENT: Denies any headache
Eyes: Denies any visual loss
Ears: Denies any ear pain or hearing impairment
Nose: No nasal obstruction, running or nose bleeds
Throat: Denies any sore throat
SKIN: No itching, rashes or open wounds.
CARDIOVASCULAR: No chest discomfort, edema, palpitations or chest pains.
RESPIRATORY: Coughing but no shortness of breath.
GASTROINTESTINAL: Denies nausea, vomiting, diarrhea or abdominal pains.
GENITOURINARY: Last pregnancy 9 years ago. Urinary leakage and inconsistencies.
NEUROLOGICAL: No headache, numbness, paralysis, ataxia, syncope or dizziness.
MUSCULOSKELETAL: No muscle pains
HEMATOLOGIC: Denies bruising, bleeding or anemia.
LYMPHATICS: No enlarged nodes. No history of splenectomy
PSYCHIATRIC: No depression or anxiety.
O.
Physical exam: The initial examination of patients with urinary leakage or incontinence demand a systematic approach to understand the probable causes. The physical examination of the patient began with the general medical conditions such as medical history, personal history and characterization of symptoms. The examination was tailored to the case based on the particular patient incontinence complaint, medical history and surgical history. The patient had his weight, body mass index, height, pulse and blood pressure recorded. Simple primary care tests were conducted to offer relevant information regarding the patient condition. Urinalysis and culture were conducted to detect disorders in the bladder and urinary tract. Gait assessment was conducted to determine the mobility status. Neurological examinations and cardiovascular examinations were also done to rule out some conditions. A pelvic examination was done to note pelvic organ atrophy and prolapse.
Vital signs
VSS: and normal, 5’0 172 lbs. (BMI 33.6)
VVBSU, parous, vagina somewhat gaping, 1st degree cystocele
Cervix parous, wnl
Uterus: anteverted, 10 cm, non-tender
Adnexa: without masses or tenderness
Diagnostic results:
The diagnostic tests included urinalysis, MRI, CT scan, X-Ray and blood test. The diagnostic results indicated that pregnancy and child birth are the main causes of urinary leakage due to weakening of pelvic floor muscles.
A.
Differential Diagnoses
Pregnancy and Childbirth– During and childbirth, the weight of expanding the uterus can result to weakening the strength of the pelvic floor muscles. The pelvic floor dysfunction can lead to changes in a woman’s urinary control abilities thus causing urinary leakage (Raz, 2011). The patient shows signs related to stress incontinence which is loss of urine as a result of increased bladder pressure. The muscles in the pelvic floor and bladder sphincter can be overwhelmed by the continued pressure and stress on the bladder (Aoki et al., 2017). The urine may leak due to the exerted pressure on the bladder such as laughing, coughing or sneezing.
Acute Cystitis- This is a sudden bacterial infection that leads to inflammation of the urinary bladder. The condition leads to complications such as pelvic discomfort and urination since it triggers incontinence symptoms (Reynolds, Dmochowski and Penson, 2011). It causes the bladder to get irritated and swollen resulting to urine leaking out. The patient has revealed strong and frequent urge to urinate even after emptying the bladder which is a major symptom of acute cystitis.
Uterine Prolapse- This occurs when the uterus has descended into or toward the vagina. Uterine prolapse results from the pelvic floor alignments and muscles becoming weak and no longer supporting the uterus (Rodríguez-Mias et al., 2015). One of the major signs and symptoms of uterine prolapse is urinary problems such as urine leakage and urine retention. This may have occurred after the patient gave birth due to other conditions such as pelvic floor muscle and tissues weakening and can no longer support urine retention.
Health promotion and disease prevention aim at building a health population. During treatment and diagnosis, the physical examination, patient factors and socio-economic factors are vital in understanding the condition of the patient. The diagnosis and treatment included an analysis of the patient condition through focus on medical, family, social and personal history to locate and identify the disease and health condition. The patient has shown bladder and urinary incontinence problems which has increased the risk to the patient. The treatment is customized to the patient based on the diagnosis. Understanding proper approach for pelvic floor exercise and voiding techniques would reduce the stress urinary incontinence risks. The treatment plan is effective in treating long term conditions of urinary leakage. I have learnt that treatment and diagnosis should be customized based on the patient’s medical history, socioeconomic history, severity of the condition, age and related complications. However, I would focus on more conservative treatment options that will reduce the risks of long term risks such as avoiding bladder irritants such as coffee, alcohol, maintenance of healthy weight and avoid activities that will trigger urinary leakage.
References
Aoki, Y., Brown, H. W., Brubaker, L., Cornu, J. N., Daly, J. O., & Cartwright, R. (2017). Urinary incontinence in women. Nature reviews Disease primers, 3(1), 1-20.
Raz, R. (2011). Urinary tract infection in postmenopausal women. Korean journal of urology, 52(12), 801-808.
Reynolds, W. S., Dmochowski, R. R., & Penson, D. F. (2011). Epidemiology of stress urinary incontinence in women. Current urology reports, 12(5), 370.
Rodríguez-Mias, N. L., Martínez-Franco, E., Aguado, J., Sánchez, E., & Amat-Tardiu, L. (2015). Pelvic organ prolapse and stress urinary incontinence, do they share the same risk factors?. European Journal of Obstetrics & Gynecology and Reproductive Biology, 190, 52-57.
