Читать книгу The Family Nurse Practitioner - Группа авторов - Страница 54

Susan is a 50‐year‐old Black female who presents for her annual physical with a complaint of hot flashes and night sweats. Susan reports that some of the night sweats are drenching. She is having difficulty sleeping and is finding it hard to function at work.

Susan says her symptoms have been present for about 4–8 months. They seem to be increasing in intensity and frequency. She says, “some days I think I am going crazy! I cannot sleep and I am so easily frustrated and tired all of the time.” She expresses embarrassment about sweating at work and says that she sometimes has trouble remembering things and staying focused at work meetings.

Past medical history: No major chronic medical problems, + high blood pressure at the end of her second pregnancy (resolved with the birth), + seasonal allergies.

Surgical history: Tonsillectomy at age 6. Wisdom teeth excisions at age 20.

Family history: Mother: osteoporosis, mild depression; father: cardiovascular disease (CVD), hypertension, possibly diabetes mellitus; sister (3 years older): “terrible menopause symptoms,” recently diagnosed with a thyroid problem; brother (2 years younger): hypertension; MGM: osteoporosis, depression; PGF: early CVD with myocardial infarction at age 50.

Social history: Susan lives with her husband of 19 years, their two daughters, and the family dog in a private home that they own. She is employed as an editor with a private press agency and enjoys her work. She reports feeling stressed at work lately due to difficulty remembering tasks and missing deadlines as a result. She reports that the most important recent life event was her daughter’s graduation from high school. She is happy for her daughter as she was admitted to the university of her choice, but Susan is not looking forward to having her leave home in the fall. She describes her usual day as follows: awakes around 6 a.m., makes breakfast for herself and the family, showers and dresses for work, drives to work, and is at her desk by 8:30 a.m. She leaves work around 5:30 p.m. and drives home. She makes dinner most evenings and spends time in the evening assisting her younger daughter with homework and doing household chores. She starts getting ready for bed around 10 p.m. She reports walking the dog each day for about 1.5 miles, usually in the evening unless it is too hot.

Diet: Her 24‐hour diet recall reveals a bagel with cream cheese and coffee (black) for breakfast, salad with cottage cheese for lunch, grilled fish with potatoes and salad for dinner, and no snacks. She reports that she eats out about once per week and enjoys dessert on occasion.

Substance use: Susan denies use of tobacco. She reports alcohol use as 1 glass of red wine most evenings. She denies use of recreational/illicit drugs.

Safety: She reports feeling safe at home with her husband and family. She had 1 partner long ago who threatened her physically, but she has had no contact with him for many years. Since then she has never been hit, slapped, kicked, or otherwise physically hurt by anyone. She denies ever being forced to have sexual activities when she did not want to. She uses a seatbelt and sunblock regularly and has working smoke detectors and carbon monoxide detectors at home. Her husband does have a hunting rifle, which is kept locked with the ammunition stored separately. She denies any concerns for her children or personal safety with regard to the rifle. She denies having any current concerns about HIV.

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, 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.