Reference no: EM133876591
Questions
1. What is the differential diagnosis?
2. What is the most likely diagnosis? Why?
3. What is the pathophysiology in regard to the most likely diagnosis?
4. Should tests/imaging studies be ordered? Which ones? Why?
5. What are the next appropriate steps in management?
6. What is the appropriate topic for patient education in this case?
7. Provide a list of specialties or other disciplines and indicate what contribution these professionals might make to managing the patient.
For the following case
History of Present Illness
A 66-year-old woman presents with complaints of "leaking urine" and urgency of urination for 6 to 12 months. These symptoms have persisted to the point that she knows every public bathroom between her home and work and developed clear preferences for bathrooms in certain gas stations and fast food establishments.
When she enters a new restaurant, she instinctively looks for the bathroom before being seated. Her concern is that when she is struck with the urge to urinate, she begins to leak, and she may not have more than a minute to get to the bathroom before she has an "accident." She experiences urinary frequency 8 to 10 times daily, often with episodes of leaking and occasionally with nocturia. She rates the
symptoms as 7 of 10 on a bother scale.
Pelvic floor-strengthening exercises (Kegel exercises) and OTC herbal remedies have not helped. She experiences limited benefit from fluid restriction and is careful to urinate at home before driving. She wears pads to avoid the embarrassment of leaking and soiling her clothes in public.
Review of Systems
A ROS is positive for fatigue, nausea, abdominal pain, and hematuria. The patient reported headache and dizziness. The ROS is negative for fever, chills, glaucoma, vomiting, diarrhea, constipation, SOB, or chest pain. Relevant History Medical history is significant for Cesarean section (age 34) and a total hysterectomy (age 51) for menorrhagia. Her social history includes drinking 1 glass of wine per week since age 20, and she does not use recreational drugs. She admits to smoking a half pack of cigarettes per day for the last 10 years. Her two children are grown and have families of their own. She has suffered from intermittent depression since her husband died 8 years ago. Her family history is unremarkable.
Allergies
No known drug allergies; no known food allergies.
Medications
• Acetaminophen 500 mg PRN for arthralgia.
• Magnesium 250 mg nightly for sleep.
• Calcium 1,200 mg daily.
• Vitamin D 600 IU daily.
• Multivitamin daily.
Physical Examination
Vitals: T 36.9°C (98.4°F), P 76, R 14, BP 122/78, HT 168 cm (66 in.), WT 86 kg (189.5 lbs), BMI 30.5.
General: Well-developed, well-nourished, obese woman in no acute distress.
Psychiatric: Judgment and insight intact; rate of thoughts normal and logical; pleasant, calm, and cooperative; patient appears to be happy and content without overt anxiety or depression.
Abdomen: Active bowel sounds; abdomen soft, non-tender; no masses, no hernias, no suprapubic distension.
Genital/Rectal: No bladder tenderness on palpation and no distention noted.
Atrophic external genitalia without prolapse, pelvic masses, or gross lesions. Vagina mucosa exhibits thinning and pallor with loss of rugae. No urinary leakage on cough test with a full bladder. On the rectal exam, perineal sensation intact; sphincter tone intact; able to contract the anal sphincter. Neurologic: A&O ×3; cranial nerves grossly intact; communication ability within normal limits; attention and concentration normal; sensation to light touch is intact; gait is within normal limits for age.