"Thank you for the referral of your 68-year-old female patient Susan. We met today regarding urinary incontinence and pelvic organ prolapse."
History of Present Illness:
Patient presents with a 6-month history of urinary incontinence, primarily stress incontinence with leakage during coughing and sneezing. She reports a frequency of 8-10 voids per day and 2-3 voids per night. She denies any urgency or dysuria. Urinary stream is normal. No straining to void or intermittent urinary stream.
Past Medical History:
Hypertension, managed with Lisinopril 20mg daily; Total abdominal hysterectomy 10 years ago for fibroids.
Medications:
Lisinopril 20mg daily, Vitamin D 1000 IU daily.
Allergies:
NKDA.
Social History:
Non-smoker, occasional alcohol use, works as a teacher.
Family History:
Mother with a history of breast cancer.
Physical Examination:
General appearance is well-appearing female. Blood pressure 130/80 mmHg, weight 70 kg, BMI 28.
Abdomen is soft, non-tender, and without masses.
External genitalia examination reveals normal external structures.
Pelvic examination reveals estrogenized vaginal mucosa. Urethral mobility is increased. Stress incontinence noted with cough test. Pelvic organ prolapse stage II.
POPQ examination measurements: Aa +2, Ba +2, C +3, GH 7, Pb -2, TVL 8, Ap +2, Bp +2, D 3.
Urethra is non-tender to palpation.
Investigations:
Urine analysis was negative for infection. Urodynamic studies were performed on 25 October 2024, demonstrating stress urinary incontinence.
Assessment:
Diagnosis of stress urinary incontinence and pelvic organ prolapse. Discussed conservative management options including pelvic floor exercises and pessary use. Discussed surgical options including a mid-urethral sling and prolapse repair. Risks and benefits of each option were discussed. Patient is interested in surgical intervention.
Plan:
1. Schedule patient for a mid-urethral sling procedure.
2. Schedule pre-operative assessment.
3. Provide patient with educational materials regarding post-operative care.
4. Follow-up in 6 weeks post-operatively."
"This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian."
