I Human Week 6 NR601 Heather Stanton 48F exam

CC: Fatigue and irritability HPI: H.S. comes into the clinic today with a chief complaint of fatigue and trouble sleeping that has been going on for a year or more. Patient states she has no trouble falling asleep but awakens several times throughout the night, mostly due to hot flashes and night sweats. Other symptoms include vaginal itching, redness, and dryness. Patient admits that family has noticed she is more irritability lately. Denies fevers, chills, headaches, and chest pain. Patient has not had a menstrual period for over 12 months. No significant past medical or surgical history. Problem Statement: name or initials, age, chief complaint, positive and negative subjective findings, positive and negative objective findings H.S. 48yo female G2P2002 patient with chief complaint of fatigue, irritability, and trouble sleeping. No significant past medical or surgical history. Over the past year the patient states she has had issues with frequent awakenings in the night with hot flashes and night sweats. Amenorrhea for 12 months which was preceded by oligomenorrhea. Intermittent vaginal dryness and irritation. Other associated symptoms include decreased libido, irritable mood, and 8lb weight gain. Physical assessment revealed brittle nails and atrophic vaginal changes. All other assessments are unremarkable. DDX: Menopause – Lead ALT: Insomnia, Hypothyroid - MNM Diagnostic Tests: BMP – WNL; CBC – WNL; HCG Urine – Negative; Prolactin – WNL; TSH – Normal SOAP Note