Comprehensive: menopausal symptoms, weight gain
Comprehensive: menopausal symptoms, weight gain
Patient is a 59-year-old well-nourished Caucasian female, divorced. Works part time as a home health aide. Affect basically flat punctuated by momentary smiles, possibly of nervous nature. Has multiple physical complaints.
Present Complaints:
1. Menopausal Symptoms: Had last period one year ago. Continues to experience daily hot flashes, palpitations and disrupted sleep patterns with night sweats. Has adjusted to sleep pattern disruption by getting up and reading, doing housework. Recently has taken Tylenol PM, which also helps. Is not on estrogen replacement, would like to discuss possible use.
2. Weight gain: Pt. has gained 30 pounds in 5 years.
Past History
Childhood diseases: Measles, mumps, chicken pox.
Adult diseases:
HTN
High cholesterol
Depression, “breakdown”
Operations, Hospitalizations:
Endometrial biopsy
Left breast cyst aspirated
Cholecystectomy
Childbirth x 4.
Psychiatric Illnesses: “Emotional” breakdown, remained functional, 10 years ago. Amitriptylline and one other drug for short term.
Current health status
Allergies: Penicillin – causes rash and yeast infections.
Immunizations: Hepatitis series, Mantoux every year (non-reactive), Tetanus within last 10 years. Does not take yearly flu shots.
Screening tests: Mammogram every year, eye exam every year, Pap smear, pelvic every year, dental –routine exams, every 6 months to a year.
Exercise: Exercises in morning. Does own yard work, shoveling.
Sleep: Disrupted sleep patterns R/T menopause. (See CC)
Diet: No restrictions. Would like to lose some weight.
Current Medications: Tylenol PM – prn for sleep. (Has only taken twice).
Tobacco: Smokes 5-6 cigarettes per day.
Alcohol use: Drinks beer approximately once a week.
Family Health History
Siblings: Sister - hysterectomy R/T endometriosis; has mental health problems. Brother – in his 40s, IDDM for 20 years.
Mother: Deceased – age 62, brain aneurysm.
Father: Deceased – age 78, lung CA.
MGM: Deceased – young age, CVA.
MGF: Deceased – 70-80 yrs old, CVA.
Children: 2 daughters, healthy.
Psychosocial: Lives with 2 adult children. Has ongoing relationship with male friend (4 yrs), live separately. Has been experiencing decreased sexual libido since menopause. Also is lately avoiding friends.
Review of systems
Skin: Denies rashes, lesions.
Head: Denies headaches, dizziness.
Eyes: Denies pain, itching, discharge.
Ears: Itching inside left ear for last week.
Nose/Sinus: Denies frontal sinus pain, nasal drainage.
Mouth/Throat: Denies mouth lesions, sore throat. Recently had 2 upper teeth pulled, partial being made.
Lungs: Denies cough, shortness of breath.
Cardiac: Denies chest pain, edema. BP has been going up over last year.
GI: No heartburn, constipation, diarrhea.
GU: No frequency, burning, urgency.
Genital: Has had white cheesy vaginal discharge with itching for 3-4 days. Using Monistat with marginal relief. Sexually active.
Peripheral vascular: Denies coolness or numbness in extremities.
Musculoskeletal: Has Morton’s neuroma. Needs to take off her shoes several times a day. Denies muscle or joint pain, decreased mobility.
Neuro: Denies weakness, memory loss.
Hematologic: No anemia, denies easy bruising.
Endocrine: Last period 1 year ago. Denies excessive thirst, sensitivity to heat/cold.
Psych: Is currently a little depressed mainly about weight gain.
Physical exam
General:
BP 178/90
HR 96
RR 20
Weight 184#.
Skin: 5 cm x 3 cm raised reddened area on scalp behind left ear, edges slightly scaly. No generalized scalp irritation.
Head: Symmetrical, no moles.
Eyes: Red reflex present, blood vessels appear intact, optic disc not observed. PERRL.
Ears: Tympanic membrane pearly gray and intact bilateral. L ear canal slightly red near the tympanic membrane.
Nose/Throat: Oral mucosa pink, intact. No sores or lesions under tongue. Two teeth missing upper left. No gingivitis or caries.
Neck/Lymph nodes: No palpable nodes in neck, supraclavicular, axillary areas.
Breasts: No nodes or lumps palpated in breast. Breast self-exam review done.
Respiratory: Lungs clear to auscultation, vesicular sounds throughout lung fields.
Cardiac: S1 S2 normal, no murmurs, thrills or bruits. Carotid, radial, femoral, dorsalis, pedis pulses present and equal.
GI: Bowel sounds positive in all quadrants. No tenderness or guarding to light or deep palpation. No aortic bruit. Abdomen large, soft. Liver and spleen not palpable.
Female genital: Vaginal mucosa intact. Small amount thin whitish secretion in vagina. External genitalia show well-healed herpes crater.
Musculoskeletal: Normal ROM in all joints.
Neuro: CN II-XII intact. No numbness or tingling in extremities. Alert/Oriented.
Psych: Affect fairly flat. Occasionally laughs or smiles inappropriately.
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