Missed Period

Case Study: Missed PeriodJuanita Morales is a 47-year-old G5. P5 LC 6, a Hispanic female who presents to the office complaining of lower abdominal cramping, and urinary leakage for the past day. She states the abdominal cramping, suprapubic, started several hours ago, is sharp, intermittent, and getting more frequent and painful. She tried Motrin but states it did not help.

She had a UTI years ago and it was like this, except for the incontinence. She has been more tired for the past several months. She relates she stopped getting her period about 8-12 months ago and relates her menopause was easy. She relates no medical or surgical history. She has no known drug allergies and takes no medications. Social history is negative for alcohol, tobacco, and recreational drugs. Her last exam was several years ago.

Vital signs: temperature 99.1, BP 140/ 82, pulse 88, respirations 12. Height is 5’ and weight 235 lbs. (BMI 45.89). Clean catch urine was obtained, and the urine dipstick showed SG 1.010, trace blood, neg nitrates, neg leukocytes, negative glucose, 3 protein. She thinks that maybe she had some vaginal spotting several days ago, but nothing since.

Pt relates that she has had some constipation, and increased gas for the past several months. She was using NFP for contraception prior to her stopping her period. No other urinary symptoms were reported.

Update:

Limited physical exam shows well developed, well-nourished obese Hispanic female in no apparent distress.
Breasts: pendulous, bilateral white/yellow nipple discharge noted
Abd: obese, ? mass in Abd but difficult to assess due to body habitus, otherwise soft and non-tender. Fungal dermatitis under pannus.
CVA: No cva tenderness.
VVBSU: WNL, some watery d/c noted, nitrazine positive. Vagina with pink with rugae present. Good pelvic support, no cystocele or rectocele noted.
Cervix: soft, smooth without CMT, os parous, slightly open
Uterus: difficult to assess due to body habitus however feels enlarged by bi manual exam.
Adnexa: not palpated

QUESTIONS:
What testing are you considering?
What is your differential diagnosis?