she denies seeing any blood or experiencing fecal incontinence.
Genitourinary: Susan reports some urgency and occasional leakage of small amounts of urine, especially with coughing or laughing. She denies urinary frequency; history of recurrent urinary tract infections, pyelonephritis, or renal stones; and urine dribbling or outright incontinence. She says she does not have dysuria. She reports occasional nocturia of once or twice at night, but is unsure if this wakes her or if she is awake and then feels she needs to urinate before going back to sleep.
Gynecological: Susan reports no abnormal Pap smears or gynecological surgeries. She denies vaginal or vulvar discharge, itching, irritation, soreness, burning, abnormal bleeding, or lesions. She denies pelvic pain or rash. She reports some vaginal dryness, especially noticed with sexual activity.
Pregnancy history: Susan has been pregnant twice. She is P2, G2 with two healthy living daughters aged 15 and 18 years. She reports that she breastfed each daughter, the older one for 6 months and the younger one for 8 months.
Menstrual history: Susan reports that her last menstrual period was 6 weeks ago. She reports that the menses was typical and lasted for 6 days with 1–2 days of light flow, followed by 3 days of heavier flow, and then 1–2 days of light spotting. She experienced menarche at 13 years of age and after the first few years had pretty regular periods occurring every 28–30 days. Over the past year she has had some missed periods and some with flow that was lighter than her usual pattern. She had one period with light flow that continued for about 2 weeks.
Contraception: Susan reports that she used oral contraceptive pills for contraception in the past. She has not taken any type of hormone for contraception for the past 10 years because her husband had a vasectomy when they decided not to have any more children.
Sexual: Susan reports that she is sexually active with her husband. She is mostly satisfied but notes that it has become harder to get adequately lubricated and that it takes longer to achieve orgasm. She reports she has had 6 lifetime partners and has been monogamous with her husband for over 20 years. She reports that her desire/libido is satisfactory but is less strong than it was 1 year ago. She says that this is “a bummer. We have always had a good sex life and I miss wanting it like I used to.” Her arousal is reported as satisfactory, but “it takes longer to get ready than it used to.” She usually does achieve orgasm but “it takes longer than it used to and sometimes he is already finished and I am left feeling a bit frustrated.” She denies dyspareunia. She reports their usual sexual practices include cuddling and kissing, then foreplay that includes genital manipulation, and then vaginal intercourse with penile penetration. They have used OTC lubricants recently, due to her dryness. She says she feels good and enjoys sex when it happens, but she doesn’t initiate activity or wish for it like she used to. She reports their relationship quality as, “Oh, really good. When he finishes before me we laugh about it and talk it over. Sometimes he brings me to orgasm manually, but it can take a long time.”
Musculoskeletal: Susan reports that she has noticed some vague joint and muscle pain over the past year. It seems better when she gets regular exercise and does not stop her from her usual activities.
Endocrine: Susan denies polydipsia, polyuria, polyphagia, and symptoms of diabetes mellitus type 2.
Skin/Hair: Susan denies noticing any recent skin changes or lesions of concern. She has noticed some increased acne around her mouth, skin dryness and wrinkles, and dry/thinning hair, especially on her head. She denies hirsutism or facial hair.
Hematologic: Susan denies any bleeding or bruising that doesn’t correlate to a specific injury.
Neurologic: Susan reports some numbness and tingling if her hands or feet get too cold, but not otherwise. She denies fainting, dizziness (vertigo), feeling off balance, or having difficulty walking.
Sleep: Susan’s usual bedtime routine includes nighttime washing and tooth brushing followed by reading or watching TV for about 30 minutes. She denies use of stimulants except for coffee each morning. She does wake every night with hot flashes/sweats. She is able to fall back to sleep but reports that it can take up to an hour depending on whether she needs to change her pajamas or sheets and how long it takes to feel cool again. She usually goes to bed around 10 p.m. and falls asleep around 10:30 p.m. She gets up for work around 6 a.m. most days. She reports that she usually does not feel refreshed when she wakes up.
OBJECTIVE
Vital signs: BP: 132/80 (L) sitting; P: 78; RR: 10; weight: 152 lbs; height: 5 ft 7 inches; BMI: 23.8.
General: Appears well; in no apparent distress; neatly dressed; appropriate affect.
HEENT: Head: Nontender; without masses; hair thinning slightly in some areas. Eyes: Clear conjunctivae; PERRLA intact; EOMI; fundi sharp optic discs; normal retinal arterioles; no A‐V nicking. Ears: Clear external auditory canals; TMs + light reflex and landmarks visible; hearing grossly normal. Mouth/Throat: + normal mucosa, tongue, pharynx, and tonsils; dentition in good repair.
Neck: Supple, without lymphadenopathy. Thyroid nontender, without palpable masses or enlargement. Carotids without bruits.
Respiratory: Clear to auscultation and percussion, anterior and posterior; without wheezes, rales, or rhonchi.
Cardiac: RRR: normal S1 and S2 without murmurs, rubs, or gallops.
Breasts: Without masses, skin changes, or discharge bilaterally; no lymphadenopathy.
Abdomen: Soft, nondistended, nontender; + bowel sounds × 4 quadrants; without HSM, masses, or bruits.
Gynecological: Vaginal mucosa slightly dry, rugae present; uterus firm and anteverted, nontender, without palpable masses; adnexa nontender, without palpable masses bilaterally; no lesions noted.
Rectal: No lesions or masses noted; + external hemorrhoids; nontender; + normal sphincter tone.
Extremities: Without cyanosis, edema, or clubbing; +2 pulses bilaterally. + full range of motion throughout, nontender joints without crepitus.
Neurologic: CN II–XII grossly negative; 5/5 motor strength, gait even; DTRs 2+; Romberg negative.
CRITICAL THINKING
1 What are the top three differential diagnoses to consider for Susan and why?
2 Which diagnostic tests are required for managing Susan’s condition and why?
3 What are the concerns at this point?
4 What is the plan of treatment options to be discussed with Susan?
5 What are the recommendations for referral and follow‐up care?
6 What health education should be provided for Susan?
7 What if Susan also had diabetes or hypertension?
8 What if Susan were over age 65?
9 Does Susan’s psychosocial history affect the management recommendations?
10 Are there
