| | MENOPAUSE
Doorway information about patient
The patient is a 52-year-old woman who comes to the clinic due to hot flashes.
Vital signs
. Temperature ; 37’C
. Blood pressure : 130/80mmHg
. Heart rate: 80/min
. Respiration : 12/min
Approach to the patent
Menopause
Clinical features
. Vasomotor symptoms
. Oligomenorrhea/ amenorrhea
. Sleep disturbances
. Decrease libido
. Depression
. Cognitive decline
. Vaginal atrophy
Diagnosis
. Clinical manifestations
. ^ FSH
Treatment
. Topical vaginal estrogen
. Systemic hormone -replacement therapy
Menopause is the permanent cessation of menses due to the exhaustion of ovarian follicles and loss of ovarian function . It is diagnosed clinically in woman age > 45 who have a 12 - month history if amenorrhea without evidence for other causes of amenorrhea . the manage of menopause is 51.
Woman often experience irregular menstrual bleeding for several years prior to the cession of menses(often termed the menopausal transition , or perimenopause). Menstrual cycles are considered irregular if the do not occur every 28+ - 7 days . Ovrail failure veofre age 40 is considered premature.
Menopausal woman can have vasomotor (eg, hot flashes) and hypoestrogenic (eg, vaginal dryness) symptoms , which are most often reason for seeking medical care. Occasionally , woman may come to discuss prospect for fertility to to discuss long-tern complications of menopause (eg, osteoporosis).
Different diagnosis
Menopause and thyroid disorder have similar clinical manifestations. Features suggesting hyperthyroidism include heat intolerance , tremor , weight loss , hyperreflexia , and palpitations . Pituitary disorders are suggest by disruption of menses with additional endocrine (eg, galactorrhea ) or mass effect symptoms (eg, headache , visual field defects). Finally , pregnancy should be considered , especially in woman age <45 or who are sexually active without reliable contraception .
HISTORY AND PHYSICAL EXAMINATIONS
The history should be directed to excluding other causes of abnormal menstruation and assessing the impact of menopausal symptoms on the patient’s quality of life.
History
History of present illness
. When was your last menstrual period?
. How old were you when your first began having periods? Hone did your periods start become irregular?
. Are you symptoms impacting your sleep & quality of life?
. Do you feel any burning or pain when urinating ?
. Have you had any pain with sexual intercourse?
. How has your mood been recently?
. Do you have nay headaches ?
. Have you had any weight changes?
Past medical history
. Have you had any pregnancies? Were there any significant complications?
. Have you had any problems involving your uterus or ovaries?
. Have you had a hysterectomy or any other surgeries ?
. Do you have a history of cancer , especially cancer of the uterus , ovaries , or breast?
. Have you had nay abnormal blood clots in your veins?
Medications/ allergies
. Do you take nay medications?
. Have you taken nay over-the - counter or herbal products for menopause?
Social history
. Do you smoke? When did you start,& how much do you smoke?
. Do you drink alcohol ? How much & how often?
. Have you used recreational drugs?
Remember that genital and pelvic examination are not permitted in the USMLE Step 2 CS exam . If these examinations are indicated , list them in the Diagnostic Studies section of your documentation.
Physical examinations
General
. Examine body habitus
. Assess skin texture & jar distribution
Neck
. Examine for thyromegaly
Abdomen
. palpate ofr masses & tenderness
Psychological
. Assess mood & affect
Closing the encounter
Patient may have different concerns ranging from distressing perimenopausal symptoms , impacts on fertility , or risk for long-tern complications. Some women may simply want reassurance that what they are experiencing is normal . Although treatment is not tested as part of the Step 2 CS exam, treatment options will differ depending on the patient’s most bothersome symptoms , os this should be discussed as well . If the patent is having significant hot flashes, note wherever she has an intact uterus or any contraindications to systemic estrogen therapy (eg ,smoking , history of breath cancer ).
Diagnostic studies
Menopause is usually diagnosed clinically , and the pattern of menstrual bleeding is a more reliable indicator the hormone levels . Serum FSH may be useful for woman with cessation of menses age <45 to in older woman whom he diagnosis is uncertain (eg, hysterectomy), but it is not necessary for most women . - Estradiol and progesterone levels - decrease gradually during the menopausal transition but are highly variable and not a reliable indicator of menopause.
Patient with symptoms suggest hyperthyroidism should have a - serum TSH -. A - serum prolactin level -0 should be considered for patient with features suggesting a pituitary etiology (eg, galactorrhea ). Finally , a - serum hCG - should ordered for younger women with irregular menses and any women in whom pregnancy is a possibility.
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2018/05/24 09:53pm 
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