This is a case study. I want you to treat this like a patient that is in your practice. Based on the below information tell me:
S: Questions you would ask based on her C/C, social history, and PMHX.
O: What body systems would you examine (This is a walk in patient, and I expect a focused exam based on C/C).
A: Your 1st diagnosis should be the most likely for this patient then 2 differential diagnoses.
P: What you would order and rationale, education, and follow up.
Ms. Smith, a 54-year-old caucasian, is in your office for a 20 minute “problem visit”. She is not a new patient to this practice, but you have never seen her before. She was worked into your schedule with a complaint of “severe hot flashes”.
On presentation she says she has been having trouble sleeping and experiencing “severe hot flashes” and she is “can’t stand another minute of having these hot flashes!”
She is 5 ft 3 in tall, weighs 249 lb. NKDA. She is married and works outside the home as a sedentary receptionist job at a local resort hotel. She has a history of hypertension and high cholesterol. On medications daily for both.
Her chart lists her last menstrual period as having occurred 5 years ago, and she admits to “occasionally smoking when stressed”. She is a G3T2P0A1L2. Her children are married and do not live in her home
She has never had surgery or any major accidents.
Her family history includes: diabetes and cardiovascular disease (CVD).
Preventative screening: Pap smear 3 years ago, normal, no hx abnormal paps. Mammogram 1 year ago- no abnormal findings.
Her mother had a venous thromboembolism at 52 years of age following a serious car accident and extended hospitalization.
In a discussion with the medical assistant on admission to the exam room, she confirmed the hot flashes were “very uncomfortable” but did not answer when asked whether she was having any other symptoms. During a follow-up discussion, she was told some women experience vaginal dryness at this time of life, and she was asked directly, “Are you having any discomfort with intercourse?” Ms. Smith admitted having “some” discomfort.
Fill out the attached form regarding Ms. Smith and submit to the drop box.
