Write the Assessment and plan part of this case ?(what medication recommended if any, which medication need to be discontinued if any? And why? What are problem listed ?
Case
Chief Complaint: “I have been having hot flashes for the past few months, and I just can’t take it anymore.”
HP: EP is a 50-year-old woman who reports experiencing two to three hot flashes per day, occasionally associated with insomnia. She also states she is awakened from sleep about two to three times per week needing to change her bed clothes and linens. Her symptoms began about 3 months ago, and over that time they have worsened to the point where they have become very bothersome. She states that her mother was prescribed a pill for this, but she is hesitant to take the same thing custom essay writing service because she heard on the news and from friends that the medication may not be safe. She also does not want to “get her period back” if possible. Successfully treated for depression in the past, she is currently controlled on paroxetine therapy. She exercises three times a week and tries to follow a low-cholesterol diet.
PMH
• Depression
• GERD
• HTN
• Hypothyroidism
FH
Mother died of stroke at age 67; father died of lung cancer at age 62. Patient has one brother, 52, and one sister, 48, who are alive and well, but both with HTN.
SH
Married, mother of two healthy daughters, ages 21 and 25. She is an RN in a neighboring physician’s office. She walks on her treadmill three times a week and is trying to follow a dietitian-designed low-cholesterol diet. She does not smoke and occasionally drinks a glass of red wine with dinner.
Meds
• Hydrochlorothiazide 25 mg PO once daily
• Omeprazole 20 mg PO once daily
• Paroxetine 20 mg PO once daily
• Synthroid 0.075 mg PO once daily
Allergy
NKDA
ROS
(+) Hot flashes, occasional night sweats and insomnia, vaginal dryness. (–) weight gain, constipation. LMP 12 months ago.
Physical Examination (only pertinent noted)
Gen: WDWN female in NAD
VS:BP 128/86 mm Hg, P 78 bpm, RR 15, T 36.4°C; Wt 76.2 kg, Ht 5′6″
Genit/Rect: Pelvic exam normal except (+) mucosal atrophy; stool guaiac (–)
Ext
(–) CCE; pulses intact
Neuro
Normal sensory and motor levels
Labs
Na 136 mEq/L Hgb 12.7 g/dL Ca 9.3 mg/dL Fasting lipid profile
K 3.9 mEq/L Hct 39.3% AST 32 IU/L T. chol 190 mg/dL
Cl 104 mEq/L WBC 6.5 × 103/mm3 ALT 30 IU/L LDL 132 mg/dL
CO2 25 mEq/L Plt 208 × 103/mm3 TSH 2.46 mIU/L HDL 50 mg/dL
BUN 10 mg/dL FSH 87.8 mIU/mL Trig 180 mg/dL
SCr 0.7 mg/dL UPT (–)
Random Glu 98 mg/dL
Other
Pap smear and mammogram: Normal
