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History and Physical Stress Incontinence

History and Physical Stress Incontinence

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History and Physical #1. Urinary Incontinence

  • Date: November 1, 2014
  • Name: P.M
  • Date of Birth: 6/20/1976
  • Age: 38/li>
  • Health Insurance Plan: Horizon Blue Cross/ Blue Shield of New Jersey. Direct 10.
  • Gender: Female
  • Marital Status: Married
  • Language: English
  • Referral: None.
  • Source and Reliability: Self-historian


Inability to control urination.


Patient is a 38-year-old white female who complains of urine leakages over the past month or so. She has been suffering from leakages during sessions at the gym, when lifting her children and heavy shopping bags, and upon laughing hard or sneezing. The patient is feeling self-conscientious and mildly anxious. Leakages vary from mild to a moderate amount that can cause embarrassment. She reports that she has resorted to wearing panty liners “just in case.” The patient hopes to get the proper medical attention to cure her condition because it is interfering with her daily activities and responsibilities.


  • Impaired Physical Mobility
  • Impaired Verbal Communication
  • Disturbed Sensory Perception
  • Patient denies any psychiatric history.
  • Patient denies urinary incontinence until recently.

Health Maintenance

  • Undergoes annual physical examinations
  • Last dental exam: December 10, 2013
  • Last complete physical: September 30, 2013
  • Eye exam: March 16, 2014.
  • Immunization status: DTaP November 2001
  • PAP Tests every 3 years. Last test June 11, 2013.
  • Annual influenza September 2013
  • Lipid disorder screening: September 7, 2013 negative.

Family History

  • Mother - 64 years old, high cholesterol, irritable bowel syndrome.
  • Father - 67 years old, glaucoma
  • Paternal grandfather - 85 years old, arthritis, COPD, dementia.
  • Maternal grandfather - 81 years old, dementia, depression
  • Sister - 30 years old, no known medical condition.
  • Sister – 34 years old, borderline high cholesterol..


  • Multivitamin 1 tablet po daily for health maintenance.
  • Caltrate 600+D Calcium Supplement. 1 tablet po for health maintenance.
  • Omega-3 (500mg tablets) 2 tablets po for health maintenance.

Allergies: Penicillin.


  • Patient is married for 7 years.
  • Lives with her husband and her 4 year old daughter and 3 month old son.
  • Paternal grandfather - 85 years old, arthritis, COPD, dementia.
  • Husband works for PSE&G.
  • Maintains a healthy diet.
  • Close family ties.
  • Large circle of friends
  • Active member in her community and church.
  • Enjoys outdoor activities
  • Listens to classical music
  • Plays the violin
  • Enjoys traveling, but has not traveled since she became pregnant in 2013.

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Current Health Habits:

  • Patient does not smoke or consume alcohol.
  • Maintains a healthy diet.
  • Keeps well hydrated
  • Drinks 1-2 cups of caffeinated coffee in the morning
  • Juices her fruits and vegetables.
  • Participates in cardio aerobic step classes and kick-boxing classes 4 times a week
  • Enjoys yoga on Sunday mornings

Review of Systems:

General: Patient denies weight changes, fatigue, night sweats, chills or fever. Skin, Hair, Nails: Denies unusual nail or hair growth, lesions, or rashes.

Head and Neck:

  • Head: Denies headaches, dizziness, light-headedness, or any other head injury.
  • Neck: Denies neck stiffness or difficulty in swallowing
  • Eyes: Does not wear glasses, denies pain or discharge, discomfort or visual disturbances.
  • Ears: Denies vertigo, pain, tinnitus, discharge or changes in hearing.
  • Nose and sinuses: Denis any change in sense of smell, nosebleeds, congestion, post-nasal drip, sinus pain, or colds.
  • Mouth and Throat: Denies any change in voice, sore throat, bleeding gums, ulcers, difficulty chewing or swallowing.
  • Breasts: Denies pain, tenderness, lumps or discharge.
  • Cardiovascular: Regular beat, no murmurs, normal S1 and S2, no friction ribs, gallops or evidence of tachycardia.
  • Peripheral vascular: Denies swelling, extremities pain, claudication or change in color.
  • Chest and lungs: Denies cough, tight chest, hemoptysis, orthopnea or wheezing.
  • Endocrine: Denies heat/cold intolerance, skin or hair changes. Admits to occasional lower than usual energy levels.
  • Hematologic: Denies unexplained bleeding or bruising.
  • Lymphatic: Denies lymph node enlargement, tenderness or pain.
  • Gastrointestinal: Denies change in appetite, diarrhea, constipation, bloody stools or tarry stools.
  • Genitourinary: The patient does not suffer from urgency, polyuria, nocturia or dysuria. Admits urinary incontinence.
  • Gynecological: Denies heavy menstrual periods or irregularities, dysmenorrhea, vaginal bleeding, pain or discharge.
  • Musculoskeletal: Denies restriction of movement, joint pain, stiffness or swelling.
  • Neurologic: Denies weakness, seizures, imbalance or shakes.
  • Mental status and Psychiatric: Denies irritability, or any suicidal ideation. Experiences sleeplessness due to worry about stress incontinence.


  • General: Patient is a 38 year old Caucasian female appears to be in mild distress. She is neat and clean, communicates her concerns and needs well.
  • Vitals: Temp. HR-98, 98.6 F, Bp- 110/71, RR-13, Sao2- 97 Room air, HT: 5’6, WT: 139 lbs.
  • Mental status: Alert, oriented to time, place and person. Her attention span and memory are intact.
  • Skin, Hair and Nails: Skin is pink, warm, dry, and intact. Her nails are firm, but not brittle. No rashes or lesions. Good cap refill.
  • Head: Normal size, with no moles, lesions, or other suspicious markings. Symmetrical facial features. Temporal arteries are soft but non-tender. Scalp is clean, well-maintained and moveable.
  • Eyes: Sclera is white, no jaundice color, and no edema, discharge or strabismus. Conjunctive is pink without ptosis. PERRLA, 20/20 vision and equal visual fields. No ulcers or corneal abrasions. The lens is clear with a red reflex. No exudates or hemorrhaging
  • Ears: Auricles intact. No lesions, redness or masses. No pain. Ear canals are clear and lack large build ups of cerumen; TM is white and clear,+ light reflex and bony landmarks positioned at 5 o’clock. No eardrum perforation or drainage. No signs of otitis media or otitis externa.
  • Nose and Sinuses: Maxillary and frontal sinuses are not tender. No rhinitis or redness. The patient’s mucosa is pink and moist. No nasal flaring or polyps.
  • Throat and mouth: No redness on the patient’s pharynx. Mucosa is moist and pink. No lesions, redness or swelling of the tongue. The gingivae are pink, no bleeding. The patients’ Tonsils note no of edema. Teeth are white and are in a relatively good condition.
  • Neck: Trachea midline, thyroid and cartilages are movable with swallowing. Thyroid slightly enlarged. No nodules or goiters.Non-palpable lymph nodes. No stiffness or tenderness. Able to move neck in all directions without difficulty.
  • Chest and Lungs: No petechiae, lungs clear. No wheezing, rales or ronchi. No cough. Vesicular breath sounds with no adventitious sounds throughout lung fields. RR-12. No use of accessory muscles. No barrel chest. Symmetrical tactile fremitus.
  • Heart: Tachycardia 111. Regular rhythm; S1 and S2. No S3 or S4, no gallops, murmurs, or friction rubs.
  • Abdomen: Abdomen soft, non-distended, non-tender, with no rebounding. Positive bowel sounds x 4 quads. No nausea or vomiting. No splenomegaly or hepatomegaly. Liver, spleen, and kidney non palpable; no tenderness on palpation.
  • Lymphatic: No palpable lymph nodes in neck, supraclacvicular, axillary or inguinal areas.
  • Musculoskeletal: Able to move all extremities without difficulties. Hand and leg grasps are strong 5/5, equal bilaterally. No muscle atrophy or weakness. Full range of motion in all extremities. No swelling, tenderness or joint deformities.
  • Neurologic: Follows commands. Good balance and coordination. AAOx3 Gait steady. No focal or sensors deficits. Strong, positive reflexes, and cranial nerves 2-12 are intact.

Diagnostics (October 25, 2014).

Na 137 mEq/L, K 4.1 mEq/L, Cl 100 mEq/L, Hgb 12.1 g/dL, Hct 34.7, WBC 7.1, TSH 0.45 mIU/L, Free T4 0.71 ng/dL, Free Anti-TPO antibody negative, CO2 24 mEq/L, BUN 10 mg/dL, Glu 85 mg/dL, MCV 90 m3, Ca 8.7mg/dL, Mg 1.9mg/dL, PO4 2.6 mg/dL, albumin 3.7 g/dL, ASR 20 IU/L, T. Bili 0.3 mg/dL, Alk phos 60 IU/L, Cholesterol 168 mg/dL, LDL 128 mg/dL, HDL 82 hg/dL, triglycerides 57 mg/Dl.


  • First diagnosis: The purpose of the patient’s initial visit was to ascertain what was causing her urinary leakage.
  • Acute problems:
  • Chronic problems: Differential diagnosis:

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