Case Scenario 2
Table 1
Testing or
Management
Example:
Urinalysis and
Urine culture
Define and
describe
Lab tests to
assess and
rule out UTI
Candidates eligible for this Special
include:
consideration
Performed on all patients n/a
who are having urinary
symptoms especially,
dysuria, urinary frequency,
urgency, and urinary
incontinence
Urodynamics
Pelvic Floor
Muscle
Therapy
Percutaneous
Tibia Nerve
Stimulator
Pessary
Therapy
Surgical
management
Type of
incontinence
Stress
Incontinence
Urge
Incontinence
Nocturnal
Incontinence
Transient
Incontinence
Definition and
Example
How to assess
Treatment/
Management
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 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?
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