“I have been experiencing urine leakage during physical activities like coughing, laughing, or exercising”: SOAP NOTE.

The patient is a 54-year-old Hispanic female who reports a 6-month history of urinary leakage associated with activities such as sneezing, coughing, laughing, or exercising. She states the incontinence has progressively worsened, and she now wears liners daily.

Denies urgency, dysuria, nocturia, or hematuria. No fever, chills, or weight loss. She denies any recent UTI but notes that the leakage has affected her quality of life and social engagement. She has not tried any treatments yet.

Lisinopril 10 mg daily – for hypertension

Multivitamin – general health

Allergies:

NKDA

Medication Intolerances:

None reported

Chronic Illnesses/Major traumas;

Hypertension

Hospitalizations/Surgeries

Has never been diagnosed with diabetes, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid issues, kidney disease, or psychiatric conditions.

Mother: HTN, DM
Father: deceased (MI)
No family history of kidney disease or urologic conditions

High school graduate. Works part-time as a receptionist. Married, lives with husband. No tobacco, alcohol, or drug use. Feels safe at home and work.

No weight change, no fatigue, no fever or chills

No chest pain or palpitations

No rashes or lesions

No dyspnea or cough

 No vision changes

No N/V/D, no abdominal pain

No hearing loss or tinnitus

Reports urinary leakage with physical exertion; denies dysuria or urgency

Menopausal x3 years. Last Pap smear 2 years ago—normal. No vaginal discharge

No sore throat or nasal discharge

No joint pain

No lumps or nipple discharge

Syncope, seizures, transient paralysis, weakness, paresthesias, blackout spells

No bruising, no heat/cold intolerance

No depression or anxiety

Healthy-appearing adult in no acute distress.

Intact, no rashes

Normal findings

RRR, no murmurs

Clear on auscultation

Soft, non-tender, no masses

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.

Bladder non-distended. No CVA tenderness. Normal external genitalia. No lesions. Vaginal walls well rugated.

No masses or prolapse noted on bimanual exam. Uterus non-tender. No adnexal masses.

Normal ROM in extremities

Alert, oriented x3, normal gait and coordination

Appropriate mood and affect, cooperative

None ordered at this visit

§  Fluorescein Stain Test: Not performed. No signs of corneal abrasion or ulcer based on clinical evaluation.

§  Visual Acuity Test: Normal in both eyes (20/20), no reported vision changes.

§  Eversion of Eyelid: Not performed due to absence of foreign body sensation or trauma.

§  Photophobia Test: Negative. No discomfort upon light exposure.

§  Lymph Node Palpation: No preauricular or cervical lymphadenopathy palpated.

o    1- Stress urinary incontinence (ICD-10 Code: N39.3)
This is a medical condition that is marked by involuntary urine leakage when a person sneezes, coughs, or works out. It has mostly been linked to pelvic floor muscle weakness or hypermobility of the urethra (particularly in postmenopausal women or women with childbirth history) (Lugo & Riggs, 2020).

The patient states that she does not experience urinary urgency or nocturia but only loses urine when the abdominal pressure increases, which confirms the classical manifestation. This is the main diagnosis due to the lack of irritability of the bladder or a lack of infection.

o    2- Urge urinary incontinence (ICD-10 Code: N39.41)
Defined as an urgent and sometimes insatiable pull to urinate that is followed by involuntary urine incontinence, commonly linked with overactive bladder or detrusor overactivity. It can be accompanied by the presence of nocturia and frequency as well (Nandy & Ranganathan, 2022).

o    3- Mixed urinary incontinence (ICD-10 Code: N39.46)
It is often described by a strong urge to urinate with mysterious leakage, and it can frequently follow overactive bladder or detrusor overactivity. It can be accompanied by nocturia and frequency as well (Harris & Riggs, 2020).

Although this is still in the differential since it is the result of changes to the bladder associated with aging, the fact that the patient does not experience urgency, frequency, or a nocturic pattern makes this diagnosis less likely in this situation.

Diagnosis

o    Stress urinary incontinence (ICD-10 Code: N39.3)
A condition characterized by involuntary leakage of urine during activities that increase intra-abdominal pressure, such as coughing, sneezing, or physical exertion. It is most often caused by weakened pelvic floor muscles or urethral sphincter incompetence. In this case, the patient’s symptoms of urine leakage during exertion without urgency, frequency, or nocturia confirm this diagnosis.

§  Further Testing:

§  Urinalysis and urine culture to rule out infection as a contributing factor

§  Bladder diary for three consecutive days to assess voiding patterns and incontinence episodes

§  Optional: Referral for urodynamic testing if symptoms persist or fail to improve with conservative management

§  Medication:

§  No pharmacologic treatment initiated at this time, as first-line management for stress incontinence is non-pharmacological

§  Consider vaginal estrogen therapy if vaginal atrophy becomes apparent during follow-up, especially if postmenopausal

§  Education:

§  Educate the patient about stress urinary incontinence, risk factors, and prognosis

§  Review the importance of weight management and avoiding bladder irritants (such as caffeine, alcohol, and carbonated drinks)

§  Instruct on performing pelvic floor muscle exercises (Kegel exercises) regularly—recommended 3 sets of 10 repetitions daily

§  Encourage lifestyle modifications, including regular physical activity and avoiding heavy lifting

§  Non-Medication Treatments:

§  Referred to pelvic floor physical therapy for guided pelvic strengthening and biofeedback

§  Advised trial of bladder training techniques (timed voiding)

§  Discussed potential future options such as pessary use or surgical referral if conservative therapy fails

The patient was not only active on the visit but also responsive and attentive. She had some worries about the effect of the urinary leakage on her quality of life, and she was fairly well informed of the diagnosis and prescribed treatment course. The patient asked appropriate questions and did not hesitate to read educational materials and change her lifestyle.

She expressed the desire to take up pelvic floor exercises and start keeping a bladder diary. Follow-up would follow to measure the success of conservative management and seek other further interventions in case necessary.

Reason given by the patient for seeking medical care “in quotes”

Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.

Allergies:

Medication Intolerances:

Chronic Illnesses/Major traumas

Hospitalizations/Surgeries

“Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”

Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.

Education level, occupational history, current living situation/partner/marital status, substance use/abuse,

Weight change, fatigue, fever, chills, night sweats, energy level

Chest pain, palpitations, PND, orthopnea, edema

Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles

Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB

Corrective lenses, blurring, visual changes of any kind

Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools

Ear pain, hearing loss, ringing in ears, discharge

Urgency, frequency burning, change in color of urine.

Contraception, sexual activity, STDS

Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx

Male: prostate, PSA, urinary complaints

Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain

Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis

SBE, lumps, bumps or changes

Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells

HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase

hunger, cold or heat intolerance

Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx

Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later.

Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.

Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent.

Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.

Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.

Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.

Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized.

A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present.

On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.

No adnexal masses or tenderness. Ovaries are non-palpable.

(Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )

(Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).

Full ROM seen in all 4 extremities as patient moved about the exam room.

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Urinalysis – pending Urine culture – pending Wet prep – pending

o    1-

o    2-

o    3- Diagnosis

o

§   Further testing

§   Medication

§   Education

§   Non-medication treatments