New Prolapse/Incontinence Consult

Patient Information: - Jane Doe - 58 - Female - 555-123-4567 Reason for Visit: - Jane presents with concerns of urinary incontinence and pelvic pressure. History of Present Illness: - Symptoms began approximately 6 months ago, with gradual worsening. Jane reports urinary leakage when coughing or sneezing and a sensation of pelvic heaviness. - Associated symptoms include mild pelvic discomfort and increased urinary frequency. - Jane has tried pelvic floor exercises with minimal improvement. Bowel Function: - Constipation: 2-3 times per week - Hard stools, straining required - Over-the-counter laxatives used occasionally Fluid Intake: - 2 liters of water daily - 1 cup of coffee in the morning - Occasional herbal tea in the evening Past Medical History: - Hypertension, managed with medication - Appendectomy at age 25 Medications: - Lisinopril 10mg daily - Multivitamin Allergies: - Penicillin Social History: - Non-smoker, drinks alcohol socially - Walks 30 minutes daily Family History: - Mother had uterine prolapse Review of Systems: - No other significant symptoms reported Physical Examination: - Pelvic exam reveals mild anterior vaginal wall prolapse - No significant tenderness noted Assessment: - Stress urinary incontinence with mild cystocele Plan: - Recommend pelvic floor physical therapy - Consideration of pessary fitting - Discussed lifestyle modifications including weight management Follow-Up: - Follow-up in 6 weeks to assess progress and consider further interventions Once again, thank you for involving me in her care.