A 53-year-old, G1 P1, female presents to your clinic with an 8 month history of vasomotor symptoms. She averages 6 or more hot flashes per day and is frequently awakened by night sweats. She feels that her symptoms make it difficult for her to concentrate and cause her to be irritable, affecting her ability to do her job and negatively impacting the quality of her relationships. She is sexually active and experiencing a decrease of libido and is thinking about getting a divorce.
She has an intact uterus but has had no menstrual periods for 1 year. She is 5’7″ in height and weighs 126 lbs, for a body mass index (BMI) of 19.8. She does not routinely exercise and has smoked 1 pack of cigarettes per day for 20 years. Although she takes a multivitamin/mineral tablet each day, SP is uncertain about the doses of calcium and vitamin D provided by this supplement. Her mother and a maternal aunt had osteoporosis, and her mother has sustained a hip fracture. SP has no family or personal history of breast cancer and has not had a breast biopsy.
SP is uncertain about hormone therapy because of the negative things she has heard via the news and her friends. She is concerned about the possibility of developing breast cancer even though she has no personal or family history of this disease. She is also concerned about the possible risk of developing Alzheimer’s disease. She does not voice any concern about bone health.
With the above information, construct the patient’s subjective data in a SOAP Note format.
How would you diagnose and treat vaginal atrophy?
Discuss general treatment of menopause and osteoporosis with hormones.
How would you counsel this client?
Include a discussion of bio-Identical hormones and compounding with saliva testing. Be sure to discuss what
subjective/objective data you need before you prescribe.