Dalisay Edwards ihuman OBGYN Case Study

Reason for encounter

Fatigue – concerned something is wrong

History of Present illness (HPI)

Dalisay Edwards, a 42-year old female presents for evaluation of missed menses, fatigue, night sweats, and inability to sleep well. Her menstrual irregularity begun 2 years ago after the death of her mother. Initially, she missed her periods for two months before they resumed, became irregular then completely stopped. It is now 9-12 months since her menses stopped. Her fatigue begun at the same time that she couldn’t sleep well in the last several months. She denies change in the fatigue over time. She stays in bed for 8 hours every night but barely gets 4 hours of good sleep. However, every time she wakes in the middle of the night she can fall asleep again. She falls asleep almost immediately and wakes up 2 hours later feeling hot and sweaty when she takes off the blankets, fall back to sleep and wake up freezing and pull the blankets on. She does this multiple times a night. Other times, she has to change her bedclothes as they get drenched with sweat. She gets night sweats every night approximately 3 or 4 times. She denies any treatments for her fatigue, night sweats, missed menses or menstrual irregularity. She has unintentionally gained 5 pounds. She denies pain with intercourse.

Problem Statement

The patient is a 42 year old G2P2002 who presents with complaints of fatigue and amenorrhea. She had normal energy and menstrual periods until about 2 years ago. Following the death of her mother, they stopped for 2 months and then resumed abit less regular. Approximately 9-12 months ago they stopped completely. She also complains of night sweats x 3-4 times per night over this same period of time. Family members have noticed she is abit more short tempered (cranky). PMH no major medical problems. Vitals and PE are normal for stated age.

ORDER DALISAY EDWARDS OBGYN CASE STUDY NOW

Management Plan

Diagnostic tests

None

Medications

Extradiol (transdermal patch) 0.025-0.05 mg once weekly (Lega et al., 2023).
Atorvastatin 10mg PO 24 hourly

Consults/referrals

None

Client education

You have been diagnosed with menopause. This is a natural biological process that marks the end of a woman’s reproductive years following 12 consecutive months without menstrual periods. It generally occurs between 45-55 years old but may occur earlier due to surgery, genetics, or other underlying medical conditions (Lega et al., 2023).
Common symptoms during menopause include; mood changes, vaginal dryness & discomfort, night sweats, hot flashes, night sweats, sleep disturbance, weight gain and changes in metabolism, dry skin, thinning hair, forgetfulness and difficulty concentrating (Lega et al., 2023). The long-term risks resulting from menopause include osteoporosis, insulin resistance due to metabolic changes, and cardiovascular disease.
The management of menopause focuses on improving the quality of life (QoL) and reducing the severity of symptoms through lifestyle modification and hormone replacement therapy (HRT) (Lega et al., 2023).
Engage in both strength training and aerobic exercises to improve your cardiovascular health and insulin sensitivity.
Relaxation exercises such as yoga and mindfulness help to regulate stress hormones which affect both cardiovascular health and sugar.
Avoid consumption of excess sugar and processed foods, consume diets low in saturated fats, but rich in omega-3 fatty acids, and fiber to maintain a healthy BMI.