52 O/F with a Complaint of hot flashes

Vitals

• B.P 140/80

• Pulse 80/min and regular

• RR is 16/min  

• Temp. 98.8⁰F

Communication and Data gathering

• "Hello Mrs. Armstrong; I am Dr. Jones" ("Hello Dr")  "Good morning." ("Good morning Dr")  "Nice to meet you." ("Nice to meet you to.")

• "What brings you in today?" ("I keep having hot flashes and they’re driving me crazy.")

• "When did they start?" ("Around three months ago.")

• "How often do they happen?" ("About 10 times a day.")

• "Do you feel anything else when these flashes occur?" ("I sweat a lot and I feel my heart racing.")

• "Do you have any warning beforehand?  I mean do you feel it coming on before it really starts?" ("Yes Dr, I do. It sometimes even disturbs my sleep.")

• "How do you feel most days?  How has your mood been the last three months?" ("I don’t know Dr. I feel dull, sometimes I can’t control my temper, and most of the time I just want to be left alone. I don’t feel on top of things. This whole thing is driving my husband crazy.")

• "Do you feel any burning or pain when urinating?" ("Yes, I do. I find that I have to rush to the bathroom both day and night.")

• "When did you have your last menstrual period Mrs. Armstrong?" ("About a year ago.")

• "Do you have any problems with your bowels?" ("No")

• "Have you had any thyroid problems in the past?" ("Yes Dr, I had a goiter 10 years ago but it was surgically removed.")

• "Do you have any other problems like high blood pressure or diabetes?" ("No")

• Make eye contact and then say, " Mrs. Armstrong, I’m going to ask you some sensitive questions. It might be embarrassing to you, but it’s for your best interest."

• "How has your sexual life been lately?" ("I don’t know, Dr. I get a lot of burning sensation and I generally don’t show much interest because of the pain even though my husband wants to do it .")

• "Is he supportive?" ("Yeah, I guess but he is frustrated with the way I have been behaving.")

• "Do you have any other problems for which you’ve needed counseling or medication?" ("No Dr. This is the first time that I’ve been sick.")

• "Have any of your relatives been diagnosed with breast or uterine cancer?" ("Yes Dr. my sister had one breast removed.")

• "Have your arms and legs ever been swollen and painful? Have you had any blood clots in your legs?" ("No")

• "Have you ever had any pain in the legs or back (for osteoporosis)?" ("No")

• "Do you smoke?" ("No")

• "Do you drink any type of alcoholic beverage?" ("No")

• "Do you have any allergies?" ("No")

• "Do any of your family members have a history of clotting disorders?" ("No")

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