Subjective:
- Bladder: Patient reports a decrease in urinary frequency from every 2 hours to every 3-4 hours since starting pelvic floor exercises. No leakage reported.
- Bowel: Patient reports regular bowel movements, no constipation or straining.
- Sexual Function: Patient reports improved sensation and comfort during intercourse.
- Prolapse Symptoms: Patient denies any feelings of heaviness or bulging.
- Pain: Patient reports no pelvic pain.
- Past Medical History: Patient had a vaginal delivery 2 years ago. No previous surgeries.
- Medications: Patient is not taking any medications or herbal supplements.
- Social History: Patient is a stay-at-home mother, lives with her partner and child. She is a non-smoker and drinks alcohol socially.
- Compliance with Home Exercise Program: Patient reports consistent adherence to the home exercise program, performing exercises daily.
Objective:
- Physical Examination:
- Observation: No visible prolapse.
- Palpation: Pelvic floor muscles demonstrate good tone and strength.
- Strength Testing: Pelvic floor muscle strength assessed at 4/5 on the Oxford scale.
- Imaging Results: No imaging performed.
Impression
Patient demonstrates significant improvement in pelvic floor function and symptoms since the initial assessment. Continued progress is expected with ongoing adherence to the home exercise program.
Treatment
1. Education:
- Reviewed proper pelvic floor muscle contraction technique.
- Discussed bladder diary and fluid intake.
- Provided education on constipation management.
2. Manual therapy:
- Internal pelvic floor muscle release performed.
Home exercise program:
- Pelvic floor muscle contractions: 10 repetitions, 3 times per day.
- Abdominal bracing: 10 repetitions, 3 times per day.
- Diaphragmatic breathing: 10 repetitions, 3 times per day.
Plan
Review patient in 4 weeks. Continue with home exercise program. Discuss progression of exercises at next visit.
Dr. Sarah Jones, Chartered Physiotherapist
Subjective:
- [describe current issues, reasons for visit, discussion topics, history of presenting complaints etc; use subheadings of bladder, bowel, sexual function, prolapse symptoms, pain if relevant] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [describe past medical history, previous surgeries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [mention medications and herbal supplements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [describe social history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [mention compliance with home exercise program] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Objective:
- [physical examination findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [imaging results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Impression
[write a brief clinical summary including diagnoses and important contributing factors] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Treatment
1. Education:
[bullet point brief outline of education given] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
2. Manual therapy (only if done in session) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Home exercise program:
[list all exercises given, include number of sets and reps when mentioned](only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Plan
[write when planning to review, any actions mentioned as planned for next session](only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Clincian Name and credentials] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)