Initial Pelvic Health (Issues List)

"Notes transcribed via Heidi Health - patient consented verbally prior to commencing session" Patient Information: Jane Doe, Age: 34 years and 6 months, Female Works as a teacher, job involves standing for long periods. Regularly attends Pilates classes twice a week. Lives with her husband and two children, has a supportive family environment. Context: Husband present for part of the session. Referred by Dr. Smith, GP. Subjective: Chief complaints: Urinary incontinence when coughing or sneezing, pelvic heaviness, and occasional lower back pain. Requests information on pelvic floor exercises. Symptoms started approximately 6 months ago, worsening over the last month. Located in the pelvic region, with radiation to the lower back. Described as a feeling of pressure and a dull ache. Symptoms are exacerbated by coughing, sneezing, and prolonged standing. Relieved by lying down. Symptoms have gradually worsened over time. No previous episodes of similar symptoms. Impacts daily activities, particularly during exercise and social outings. Pelvic Health Symptoms: * Urinary incontinence with coughing and sneezing. * Urgency to urinate. * Frequency of urination approximately every 2-3 hours. * Drinks approximately 2 litres of water per day. * Bowel movements are regular, with no issues. * Eats a balanced diet with plenty of fruits and vegetables. * Reports a feeling of pelvic heaviness. Past Medical History: No significant past medical or surgical history. No relevant social history related to presenting issues. No relevant family history related to presenting issues. Patient Goals: Short-term physiotherapy goals: Reduce urinary incontinence episodes within 4 weeks. Long-term physiotherapy goals: Improve pelvic floor strength and function, and return to full participation in exercise and social activities within 3 months. Objective: Consent for examination was obtained verbally prior to the assessment, explaining the nature of the examination and the patient's right to withdraw consent at any time. * Pelvic floor muscle assessment: GH+PB, Prolapse: Grade 1, Strength: 3/5, Tone: Normal, Relaxation: Normal, Endurance: Reduced. * Musculoskeletal assessment: Gait normal, ROM normal, muscle strength normal. * No investigations completed. Issues: Urinary Incontinence - Impression: Stress urinary incontinence. - Differential: Urge incontinence, mixed incontinence. - Interventions performed during session: Education on pelvic floor anatomy and function, instruction in pelvic floor muscle exercises (Kegels), and lifestyle advice. - Patient response to interventions: Patient demonstrated correct technique for pelvic floor muscle exercises. - Patient education and counselling provided: Education on bladder diary, fluid intake, and avoidance of bladder irritants. Evaluation: Patient demonstrates understanding of pelvic floor exercises and is motivated to improve. Home Program: Prescribed pelvic floor muscle exercises (Kegels) 3 times a day, holding for 5 seconds, and repeating 10 times. Advised to keep a bladder diary. Handouts: Provided patient with a handout on pelvic floor exercises and bladder retraining. Plan: Follow-up appointment scheduled in 4 weeks. No need for a letter to the referring provider. Planned treatments for ongoing issues: Continue with pelvic floor muscle exercises, bladder retraining, and lifestyle advice. No referrals to other healthcare providers.