Chapter 3 SOAP Note:

S:

CC: “leaking urine”

HPI: MJ is a 57 year old woman complaining of “leaking urine.” This has been going on for 6
months, usually happening when she coughs or sneezes. In the past week it has progressed to
not being able to hold her urine, but she only voids a small amount each time she goes every 1-
2 hours. She admits to decreasing her fluid intake to try to stop the problem and as a result her
urine is dark with a strong odor. She admits to urgency, frequency and nocturia. She denies
fever, chills, nausea, vomiting, burning on urination and dysuria. MJ is frustrated with her
symptoms because she has to alter her life to plan her days around being near bathrooms.

PMH: Patient denies chronic diseases. Admits to 5 vaginal deliveries without complications.
Admits to menopause since age 49. Admits to carpal tunnel surgery on right hand age 46 and
surgery for “sinus infections” at age 28.
Medications: multivitamin daily, calcium supplements (unknown dose) daily
Allergies: Penicillin (rash and angioedema)

FH: Mother deceased, colon cancer. Father deceased age 61, myocardial infarction.
Admits to family history of diabetes, hypertension.

Social: Patient admits to mild alcohol use (drinks wine 2-3 times per month). She denies
tobacco and drug use. She admits to drinking 2-3 cups of coffee and 3-4 glasses of tea daily. She
is married and lives with her husband and dog. She denies exercise.

O:
General: Well developed, well-nourished, appears stated age. No apparent distress. Alert and
cooperative.
Vitals: BP 124/72, P86, RR 18, T 99.1, Height 5’8”, Weight 174 lbs.
Heart: RRR
Lungs: clear to auscultation
Abdomen: soft, obese, nondistended. No surgical scars. No tenderness to palpation, no
guarding or rebound. No masses or organomegaly. Bowel sounds present throughout. No
tympany to percussion.
Pelvic: atrophic changes noted of external genitalia, no erythema, lesions, masses. Vaginal
mucosa pale, loss of rugae consistent with age-related changes. Cervix parous, pale, without
discharge. Uterus anterior, midline, smooth, not enlarged. No adnexal tenderness. Rectovaginal
wall intact. Positive dribbling of urine with cough and bearing down.
Rectal: no perirectal lesions or fissures. External rectal sphincter tone intact; rectal vault with
soft brown stool; without masses.

UA: Color: dark amber, clarity: clear, SG 1.022, pH 6.5

Negative for nitrites, leukocyte esterase, protein, glucose, urobilinogen, bilirubin.

A: Differential includes urge incontinence, stress incontinence, overflow incontinence.

P: Likely urge incontinence.

- Prescribe Mirabegron 25mg QD
- Follow up with OBGYN about the incontinence.
- Continue to avoid caffeine
- Stay hydrated, keep fluid intake up
- Return for follow up in 1 month
- Call if symptoms get worse