Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Doctor working in General Practice. Your next patient is a 65-year-old woman, Margaret O'Neill, presenting with a urinary problem. Please take a history and perform a relevant examination.
Patient History:
65-year-old Margaret O'Neill - retired.
You've been having some problems with your waterworks recently, causing you quite some distress. To put it clearly, you've been having accidents. If asked to clarify, you say that for the past 3 months, you've been leaking small amounts of urine, which is incredibly embarrassing and debilitating. You can barely go about your daily activities and haven't left the house for a month now because you always need to know where the nearest toilet is. The thing is, even then, the problem isn't always related to needing to go to the toilet.
If asked specifically, you get the leaks when you cough or sneeze. You even had one time when you were laughing with your daughter, and before you knew it, you felt your clothes becoming wet – it was an awful situation! The thing is, you've always been coughing since you've had bronchitis, so you're now leaking several times a day, and you can barely leave the house.
You would say you sometimes get a sudden urge to urinate, but if you had to say which was more predominant, you'd say it was the leaking with the coughs and sneezes. You don't have any pain when passing urine, and you don't pass any blood. You are going more frequently, but that's because you need to go and change and see if you can empty your bladder. No fever or abdominal pain. Bowel habit normal.
Ideas, Concerns, Expectations:
You don't know what this is, but it's dreadful. You're ready to do anything to find a solution.
Past Medical History:
Bronchitis.
Asthma
Past Obstetric & Gynaecological History:
Three uncomplicated vaginal deliveries (one needed forceps but nothing major).
You've had a prolapse for a few years, which the doctor said is nothing to worry about.
Drug History:
Salbutamol inhaler.
NKDA.
Family History:
Your father had Parkinson’s.
Social History:
You live at home with your husband and normally manage well independently, though you've had to increasingly rely on William (your husband) for anything outside the house, like shopping and gardening.
You smoke 20 cigarettes a day and have done so since your teenage years.
You drink no alcohol.
You do occasionally drink coffee, and you always drink tea.
Examination Findings:
Abdomen soft non-tender
If gynaecological exam = protrusion from the anterior vagina.
Differentials:
Stress incontinence secondary to vagina protrusion
Urge incontinence
Mixed incontinence
Investigations:
Clinical diagnosis
If uncertain, can consider bladder diary, urine dipstick (to rule out infection), urodynamic testing (often reserved for unclear diagnoses or urge incontinence refractory to treatment)
Management (Stress Incontinence):