Prolapse/Incontinence (Gynecology)

Thank you for your referral of Jane Doe, a pleasant 58-year-old woman referred for evaluation of urinary incontinence and pelvic organ prolapse. Reason for Visit: - Jane has been experiencing urinary incontinence and a sensation of pelvic heaviness for the past year, which has progressively worsened. History of Present Illness: - The urinary incontinence began approximately 12 months ago and has gradually increased in frequency and severity. Jane reports a sensation of pelvic pressure and occasional urinary urgency. - She denies any associated pain but notes increased urinary frequency. - Jane previously tried pelvic floor exercises with minimal improvement. Bowel Function: - Jane reports regular bowel movements, occurring once daily, with no significant changes or previous treatments for bowel symptoms. Fluid Intake: - Jane consumes approximately 1.5 litres of water daily, along with two cups of coffee and one glass of juice. Past Medical History: - Hypertension, managed with medication. Medications: - Lisinopril 10 mg once daily. Allergies: - No known drug, food, or environmental allergies. Surgical History: - Appendectomy at age 25, with no complications. Gynecological History: - Last pap smear was 2 years ago, normal results. Menarche at age 13, menopause at age 52, with mild hot flashes. Obstetrical History: - G3P3, all vaginal deliveries without complications. Social History: - Non-smoker, consumes alcohol occasionally, works as a teacher. Family History: - Mother had osteoporosis, no other significant family medical history. Review of Systems: - Positive for urinary frequency and urgency, negative for other systems. Physical Examination: - Pelvic examination reveals stage 2 pelvic organ prolapse, no signs of infection. Investigations: - Urinalysis normal, pelvic ultrasound shows mild bladder wall thickening. Assessment: - Mixed urinary incontinence and stage 2 pelvic organ prolapse. Plan: - Recommend pelvic floor physical therapy and consider pessary fitting. Follow-up in 3 months to assess progress and discuss potential surgical options if necessary. Once again, thank you for involving me in her care.