OAB

1. Overactive Bladder (OAB) - ICD-10 N32.81 - Treatments attempted: Behavioral therapy (Jan 2022), Anticholinergic medication (Feb 2022), Botox injections (May 2022) - Relevant testing: Urodynamic study (Mar 2022), Cystoscopy (Apr 2022) - Current treatments: Mirabegron 50mg daily HPI: The patient, a 65-year-old female, has a history of overactive bladder diagnosed in 2021. She was referred by Dr. Smith, her primary care physician, and has been under the care of Dr. Johnson, a urologist. Baseline frequency of daytime urination was 12 times per day, with nocturia occurring 3 times per night. The patient changes incontinence pads 4 times daily, with moderate leakage severity. Previous imaging and urodynamic studies confirmed the diagnosis. KEY INFORMATION: Gynecological History: Gravida 3 Para 2, with one miscarriage. Delivered via cesarean section. Hysterectomy performed in 2015 due to fibroids. HPI TODAY [10/15/2023]: - The patient reports a decrease in urgency episodes since the last visit. - Current symptoms include mild urgency and frequency, with no nocturia. - Recent ultrasound of the bladder on 09/20/2023 showed no abnormalities. I personally reviewed and independently interpreted the scan and concur with findings. - AUA Symptom score: 12 - PVR: 50 mL "ASSESSMENT AND PLAN:" The patient is a 65-year-old female with a history of overactive bladder, currently managed with Mirabegron. 1. Overactive Bladder (OAB) - ICD-10 N32.81 - Assessment: Symptoms have improved with current treatment. - Plan: Continue Mirabegron 50mg daily, follow up in 3 months. - Counseling: Discussed the chronic nature of OAB and the importance of adherence to medication. ORDERS: - None at this time. FOLLOW UP: - Follow-up in 3 months with repeat AUA Symptom score. FUTURE CONSIDERATIONS: As above, no further considerations based on current literature.