Case #1:
Door Informafion:
Mrs. Jones
145/80
101 HR
99.8F
99 Pulse Ox
CC: Urinary Incontinence
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SP Checklist:
CC: Unable to control urination.
-Onset: Increased urgency for last year, but sometimes noticed she wets herself without noticing in past week.
-More info: Spontaneour urgency to urinate over last year, unnoticed urination this past week.
-Pain: With Urination, 3/10
-If they ask about other pain outside urination mention back pain. If they ask about radiation mention is sometimes goes down the leg and is a sharp pain.
-Day/night/exacerbating factors: if they refer to back pain, mention is hurts at night while laying down and while lifting things.
-Associated symptoms: Increased Frequency. Fatigue, Suprapubic pain.
-Happened before: Similar pain and frequency Bladder infection in her 20s
*-Fecal incontinence: yes
*-Urination at night: no
*-flank pain
*-bloody urine/change in color/odor: all no
*-weakness: weakness of left leg for 2-3 years.
*-vaginal itching: no
*-sudden urges to urinate: yes
*-sensation of full bladder: no
*-worse with bending down/cough/lifting: no
*-leakage of urine after voiding: no
*-weight loss: no
*-fevers/chills: at times feel a little warm
-loss of appetite: no
-no URI ax/change in vision/swollen lymph nodes/headaches/loss of consciousness/dizziness/confusion
- no chest pain nor *palpitations
-no SOB
-no N/V/D, no abdominal pain, but *pain below abdomen if asked. No flank pain if asked. No blood in stools nor constipation.
-*increased thirst: no, increased frequency yes.
-*muscle weakness: legs feel weak.
-no LOC/seizures/sensory losses/etc.
-no rashes
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PMH: HTN, DM, CAD
Allergies: Strawberries, NKDA
Meds (doses if asked) HCTZ 20 mg, Metoprolol 10 mg, Atorvastatin 40 mg, Metformin 500 mg BID.
Surgery: Gallbladder removed at 49, Surgery for slipped disk in lower back 10 years ago after car accident.
Social: lives with daughter’s family, works in post office, lifts heavy boxes if asked, smokes 1 PPD, drinks 2 beers a day after work, sleeps 6 hours from 12-6, eats what daughter cooks, healthy
Allergies: strawberries, NKDA
Ill contacts: no
Hospitalization: no
OB/GYN: menopausal, 3 vaginal deliveries, normal periods, bleeding 3-4 days
Trauma: MVA 10 years ago
Family: mom died breast cancer at 71, dad died of MI at 52, nothing else.
Sexual: monogamous with husband, vasectomy and post menopausal
Travel: none
CIS: CAGE, Alcohol and Smoking counseling reburied. Should express condolences for loss of relatives. Just be apologetic in general. Elicits challenge question:
Challenge question: Do you think this problem is related to me getting older?
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Physical exam:
HEENT: Open mouth, oropharynx/lip inspection
CV: Auscultate, Palpate PMI
Respiratory: auscultate
Abdominal: Inspect, Ausculate, Palpate, Assess for flank and suprapubic tenderness
Neuro: Lower extremity muscle strength, reflexes.
Findings: 3/5 weakness on knee extension, hyperreflexia is in left leg, suprapubic tenderness.
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Closure: Thank you for letting me examine you today Mrs. Jones. I understand that you’re worried about what may be happening. Based on the history and physical exam there are a few possibilities. You may have some of these issues due to an acute situation where your spinal cord is compressed and we need to do some imagine to rule that out quickly. Also, it is possible that this could be due to an infection and we are doing to run some blood tests and get a urine sample to investigate that . Does that sound alright to you?
Labs:
-Lumbar MRI
-U/A with culture
- Electrolytes (fluid status)/CBC (wbc)
-Pelvic exam (Qtip test)
-Blood Culture
Dx 1: Cauda Equina
Leg weakness
Urine/Fecal incontinence
Back pain, radiating to leg
PE:
-hyperreflexia
-unilateral knee extension weakness
Dx 2. UTI
-dm
-subjective fever
-prior uti
-dysuria
PE: -suprapubic tenderness
Dx 3. Urge Incontinence secondary to spinal lesion :
-Disc herniation
-heavy lifting at work
-back pain
-sudden urge to urinate
PE:
-hyperrflexia
-unilateral knee extension weakness.
I hope this case was helpful!!Feel free to rate X/10, point out discrepancies, ways to improve it, etc.
