Subjective: Patient presents with complaints of involuntary urine leakage with physical exertion, sneezing, coughing, and laughing, consistent with urinary stress incontinence symptoms.  She reports this has been ongoing for approximately two years and is progressively worsening, now impacting her quality of life and limiting her physical activities.  She denies dysuria, hematuria, frequency, urgency, or nocturia.  Patient reports no history of pelvic surgery, trauma, or neurological disorders.  Obstetric history includes two vaginal deliveries.  Current medications include lisinopril for hypertension.  Allergies:  NKDA.

Objective:  Physical exam reveals no abnormalities.  Pelvic exam demonstrates normal external genitalia, mild anterior vaginal wall prolapse, and good pelvic floor muscle strength with a cough stress test positive for urine leakage.  Urinalysis is negative for infection.  Post-void residual volume is within normal limits.  Assessment:  Urinary stress incontinence (USI), likely secondary to pelvic floor weakness. Differential diagnoses considered include overactive bladder and mixed urinary incontinence.  ICD-10 code N39.3, Stress incontinence, female.

Plan:  Discussed conservative management options for urinary stress incontinence including pelvic floor muscle exercises (Kegel exercises), lifestyle modifications such as weight loss and fluid management, and bladder training techniques.  Patient education provided regarding the benefits and potential risks of these treatments.  Patient agrees to begin a trial of pelvic floor therapy.  Follow-up scheduled in six weeks to assess response to conservative therapy.  If symptoms persist, further evaluation and treatment options, such as pessary fitting, urethral bulking agents, or surgical intervention, will be considered.  Referral to urogynecology may be warranted if conservative measures fail.  Patient provided with educational materials on urinary incontinence management.