QUESTION
Menopausal transition
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.
Questions:
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.
s
| Subject | Nursing | Pages | 4 | Style | APA |
|---|
Answer
Menopausal Transition
SOAP Note
Subjective
Subjective data in clinical practice entails information from a patient's point of view or symptoms. They may express their feelings, concerns, and perceptions often obtained through the history-taking process. In the case of SP, the forms of subjective data included feelings that the symptoms of vasomotor contributes to her lack of concentration and possibly triggers irritation. The patient believes that her condition affects her ability to perform her duties besides negatively affecting her relationships. Further observations suggest that SP has concerns over the possibility of exposure to breast cancer and Alzheimer's disease. She, however, harbours positive feelings about the state and health of her bones.
Objective
Contrary to subjective data, objective data in clinical practices describe patient information obtained through observable and measurable signs and symptoms. It is information obtained by the clinician through observation, physical examination, diagnostic and laboratory testing. From the patient SP, objective data include night sweats, decreased libido, intact uterus, and no menstrual period for at least one year, weight (126lbs), and BMI of 19.8. She smokes one pack of cigarettes daily for the last 20 years.
Assessment
This section entails assessing the patient presenting conditions based on data from the subjective and objective components, and it helps in the creation of differential diagnosis. Considering the patient's presenting symptoms from the subjective and objective point of view, it is possible to diagnose breast cancer. Studies indicate high risks of breast cancer for individuals with a history of smoking. Similarly, evidence indicates that the risks for osteoporosis increase with age, family, and body frame. SP's age, gender, and family history increase the chances of osteoporosis diagnosis. Similarly, the small BMI relative to height weight increases the risk of the condition.
Plan
It is possible that SP can be diagnosed with any of the conditions mentioned above; thus, an intervention plan should entail quitting smoke, increase body weight, increase the consumption of calcium and vitamin-rich food. Regular exercise contributes towards building strong bones and slow bone loss.
Vaginal Atrophy
This condition occurs when the vaginal tissues no longer work normally due to shrinking thinning out of the lining at menopause. Diagnosis of the condition is based on symptoms and physical exam of the patient. Physicians conduct a diagnosis of the condition through a pelvic exam and look for signs such as the narrowed vagina, dryness in the lining, redness, and swelling of the lining, whitish discoloration, and loss of stress. Treatment options include vaginal estrogen therapy and hormone replacement therapy, which play a critical role in acid balance restoration. Lotions and oils can be used to loosen the tissues and treat dryness (Naumova et al., 2018).
Treatment of menopause and osteoporosis with hormones
Clinical development in recent years has witnessed an increased use of hormones to treat menopausal conditions and osteoporosis. Patients presenting with the symptoms of these conditions may be subject to any of hormone replacement therapy and topical hormone therapy. Hormone replacement therapy (HRT) entails taking medication to replace hormones that the body no longer produces (Lobo, 2017). The medications are meant to help with hot flashes and vaginal symptoms and the strengthening of the bones. Topical hormone therapy entails the use of estrogen cream inserts or gel to reduce vaginal dryness. Similarly, bio-identical hormones pills, gels, patches, and creams can be used to treat menopause and osteoporosis (Rozenberg et al., 2020).
Given the patient's condition, there is a need for counseling to focus on her smoking and lack of physical activity lifestyle. The patient needs to quit smoking and increase the level of physical activities to increase bone strength. It is also necessary that she increases the consumption of calcium-rich diets.
References
Lobo, R. A. (2017). Hormone-replacement therapy: current thinking. Nature Reviews Endocrinology, 13(4), 220-231.
Naumova, I., & Castelo-Branco, C. (2018). Current treatment options for postmenopausal vaginal atrophy. International journal of women's health, 10, 387.
Rozenberg, S., Al-Daghri, N., Aubertin-Leheudre, M., Brandi, M. L., Cano, A., Collins, P., ... & Kaufman, J. M. (2020). Is there a role for menopausal hormone therapy in the management of postmenopausal osteoporosis?. Osteoporosis International, 1-16.