Medications: OTC antihistamines for allergies PRN; MVI daily; calcium (when she remembers); nasal spray for allergies PRN.
Allergies: NKDA, NKFA, +seasonal allergies.
General: Susan describes her overall health as “good, but getting weird lately.” She reports a recent weight increase of about 4 lbs. She identifies her usual weight as 145 lbs. She reports fatigue and reduced energy since her hot flashes and poor sleep began. She denies any substantive premenstrual syndrome (PMS) symptoms. “I sometimes crave salty foods or chocolate, but it is not anything big.” She denies symptoms of premenstrual dysphoric disorder (PMDD).
Mood: Susan reports her usual mood as “generally good, but I feel crabby when I don’t sleep well.” Recently she notes increased moodiness, especially after a night of poor sleep. She denies feeling nervous or anxious, but admits to feeling irritable and getting angry more easily than usual when she is tired and having more hot flashes. She says, “I feel depressed. I don’t sleep well, and most of the things I used to enjoy doing irritate me now. I feel like I am going crazy.” She denies anhedonia and with questioning says that she enjoys reading, eating out with her husband or friends, shopping with her daughters, and doing yoga classes. Susan denies eating disorders; she says, “sometimes I eat when I feel irritated, you know, comfort food like chips or chocolate; and it doesn’t even make me feel better! But no, I don’t think I have an eating disorder.”
Cognitive: Susan describes difficulty with concentration and memory, especially at work after a night of particularly poor sleep or several nights of interrupted sleep. She denies problems with cognition, noting that she thinks clearly and can follow the conversation. Her issue is “with remembering what I said I would do. If I don’t write it down, it is likely that it will not get done.” She does use lists for shopping, puts appointments in a calendar, and carries a notebook to write down tasks when at work.
Systemic: Susan reports that she began having hot flashes about 8 months ago. They have been slowly and progressively getting worse. She does have night sweats as well; sometimes she has to change her pajamas and sheets. She describes the severity of the hot flashes as 4–10 on a 1–10 scale: “sometimes they are tolerable and I just feel hot; other times I am completely drenched with sweat.” She reports having hot flashes during the day anywhere from 6 to 20 times. Her night sweats occur anywhere from 2 to 10 times nightly.
HEENT: Susan denies any problems with headaches, unless she forgets her morning coffee; and then, she says, “I get a headache around 2 p.m., but if I have a cup of coffee then it goes away. Of course then I don’t sleep well.” Susan reports minor changes in her vision over the past 3 years, requiring her to use reading glasses more and more often. She denies recent changes in hearing, smell, taste, or swallowing. She reports some increased dry eye symptoms and finds that she needs to use eye lubricating drops, especially when she is doing a lot of work on the computer. She has seasonal allergies and experiences sneezing, rhinorrhea, and itchy eyes year round and especially in the early fall.
Respiratory: Susan denies having any cough, wheeze, or shortness of breath in the recent past.
Cardiovascular: Susan denies chest pain, palpitations, dyspnea on exertion, peripheral edema, or a history of blood clots. She says that she has always had cold hands and feet: “Maybe it is Raynaud’s. They get so cold and take a long time to warm up. I am okay if I remember to wear gloves and keep my feet warm.”
Breast: Susan reports that she does do self‐breast exams, usually each month right after her period. She has forgotten often this past year since she has been missing periods. She denies any concerns or recent breast changes. She denies any discharge, pain, or tingling. She breastfed each of her daughters.
Gastrointestinal: Susan reports occasional heartburn after a large or spicy meal that is relieved with Maalox. She denies persistent abdominal pain and reports daily regular bowel movements without constipation or recent changes in color, consistency, or pattern of stools. Specifically, 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,