Full Answer Section

 

 

 

 

 

Past Medical History (PMH):

• Hypertension (diagnosed 10 years ago, well-controlled)
• Type 2 Diabetes Mellitus (diagnosed 8 years ago, well-controlled on oral medication)
• Osteoarthritis (managed with occasional paracetamol)
• Hypothyroidism (diagnosed 5 years ago, on levothyroxine)

Past Surgical History (PSH):

• Cataract surgery, bilateral (5 years ago)
• No history of hysterectomy or oophorectomy.

Family History (FH):

• Mother: Deceased, age 85, history of hypertension and stroke.
• Father: Deceased, age 70, history of diabetes and heart disease.
• Siblings: Two living sisters, both with hypertension.
• Daughter: No significant medical history.

Social History (SH):

• Lives with her husband and extended family in a rural village setting.
• Married, sexually active until recently.
• Non-smoker, rarely consumes alcohol.
• Active in her community and church.
• Primary language is Dholuo; comfortable communicating in Kiswahili.

Medications:

• Amlodipine 5 mg once daily
• Metformin 500 mg twice daily
• Levothyroxine 50 mcg once daily
• Paracetamol 500 mg as needed for pain

Allergies: No known drug allergies (NKDA).

Review of Systems (ROS):

• General: Denies fever, chills, night sweats, significant weight changes. Reports mild fatigue (long-standing).
• HEENT: Denies headache, vision changes, hearing changes. Last dental exam 2 years ago.
• Cardiovascular: Denies chest pain, palpitations, edema.
• Respiratory: Denies cough, shortness of breath, wheezing.
• Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation. Bowel movements regular.
• Genitourinary: Reports vaginal dryness, dyspareunia, occasional burning and itching. Denies dysuria, urgency, frequency, incontinence, hematuria. Denies abnormal discharge.
• Musculoskeletal: Reports chronic mild knee pain (osteoarthritis). Denies joint swelling or redness.
• Neurological: Denies dizziness, numbness, tingling, weakness.
• Endocrine: Reports feeling well controlled on thyroid medication.
• Psychological: Denies depression, anxiety. Reports good mood, but sadness about impact on intimacy.

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O (Objective)

Vitals:

• BP: 132/76 mmHg
• HR: 70 bpm, regular
• RR: 16 breaths/min
• Temp: 36.8°C (98.2°F)
• O2 Sat: 99% on room air
• Height: 155 cm (5’1″)
• Weight: 60 kg (132 lbs)
• BMI: 24.9 kg/m$^2$

General Appearance: Well-nourished, alert, cooperative female, appears her stated age. No acute distress.

Physical Exam:

• HEENT: Normocephalic, atraumatic. Conjunctivae pink, sclerae anicteric. Oral mucosa moist, dentition fair.
• Neck: Supple, non-tender, no lymphadenopathy, thyroid non-palpable.
• Lungs: CTA (clear to auscultation) bilaterally anterior and posterior. No wheezes, crackles, or rhonchi.
• Cardiovascular: S1S2 present, regular rate and rhythm. No murmurs, gallops, or rubs.
• Abdomen: Soft, non-tender, non-distended. Normoactive bowel sounds in all four quadrants. No organomegaly or masses palpated.
• Genitourinary (External Genitalia): Labia majora and minora appear atrophic. Sparse pubic hair. No lesions, erythema, or edema noted. Introitus appears constricted.
• Vaginal Exam: Vaginal mucosa appears pale, thin, and dry with loss of rugae. Erythema noted in areas, particularly posterior fornix. Minimal vaginal secretions. Cervix appears normal for postmenopausal woman, no cervical motion tenderness. No abnormal discharge.
• Bimanual Exam: Uterus non-palpable. Adnexa non-tender, no masses appreciated. Pelvic floor tone appears reduced.
• Extremities: No cyanosis, clubbing, or edema. Peripheral pulses 2+ bilaterally.
• Skin: Warm, dry, intact. Good skin turgor.

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A (Assessment)

Primary Diagnosis:

• N95.2 – Atrophic vaginitis (vaginal atrophy) secondary to estrogen decline and menopause.
  • Rationale: Mrs. Akinyi’s subjective complaints of persistent vaginal dryness, dyspareunia, occasional burning, and itching, combined with objective findings of pale, thin, dry vaginal mucosa with loss of rugae, are classic signs and symptoms of vaginal atrophy due to estrogen deficiency. Her age and 15-year postmenopausal status strongly support this diagnosis. The lack of abnormal discharge or severe urinary symptoms makes other causes less likely.

Differential Diagnoses (DDx):

1. Vulvovaginal Candidiasis (Yeast Infection):
   • Rationale: While vaginal itching and burning are symptoms of candidiasis, Mrs. Akinyi denies the characteristic thick, white, “cottage cheese” discharge. Her vaginal mucosa appears diffusely atrophic rather than inflamed with specific candidal signs. A lack of recent antibiotic use also makes it less likely, though not impossible.
2. Bacterial Vaginosis (BV):
   • Rationale: BV typically presents with a thin, watery, off-white or gray discharge with a “fishy” odor, especially after intercourse. Mrs. Akinyi explicitly denies abnormal discharge or odor. The predominant symptoms are dryness and pain with intimacy, which are not typical for BV.
3. Lichen Sclerosus:
   • Rationale: This chronic inflammatory skin condition can cause severe itching, pain, and thinning of the skin around the vulva, leading to dyspareunia and architectural changes. While some symptoms overlap (itching, pain, thinning tissue), the classic “parchment-like” or “cigarette paper” skin changes and often perianal involvement are not described. However, given persistent symptoms and potential for progression, careful monitoring for dermatological changes is warranted.