Patient Medication Profile Assignment
Analyze the given case. Consider options for this patient to control symptoms of menopause. Create a care plan and write appropriated orders for medication, if indicated. Look at all of her problems is creating your plan, not just the menopause issue.
History of present illness: M.T is a fifty-two year-old Caucasian woman who started to experience hot flashes and associated nausea a few months ago. She has tried some natural remedies without success.
Past medical history:
• Hyperlipidemia x five years, attempting to control by diet
• Gastro-esophageal reflux disease (GERD) x two years
• Last menstrual period was 1 ½ years ago. Her periods were irregular for a year before they stopped completely.
Family history: The patient’s father died of a presumed heart disease in his fifties; the mother died of complications secondary to a motor vehicle accident at the age of seventy-five. The patient is the eldest of four sisters; the others are aged forty-six, forty-three, and forty-one and are alive and well. There is no family history of breast cancer.
Social history: M.T. is married, with three adult children who are all in good health. She works as a part-time bank teller. She walks on her treadmill every day and watches her grandchildren after school during the week. She denies the use of illicit drugs, but she did smoke two and a half packs of cigarettes per day from age fifteen to forty-five. She drinks alcohol occasionally and ten to twelve Diet Cokes per day. She tries to follow a low-salt and low-cholesterol diet but admits that it is difficult. She has increased her intake of calcium-containing food (milk, yogurt, and cheese) to three to four servings per day because she did not like taking so many Tums.
Medications:
• Acetaminophen 325 mg 1–2 po qd prn for joint pain after exercise
• Prilosec 20 mg bid
• NKDA
Review of symptoms (ROS):
• Genitourinary/Rectal (GU/Rect): Case of dryness, itching, urinary frequency, and dribbling after voiding; Gravida 3, Para 3, Menarche at age 14. Last menstrual period (LMP) 1 1/2 years ago; sexually active but experiencing dyspareunia
• Mental Status: Case of insomnia, increased fatigue, and feeling somewhat depressed
Physical Examination:
• Vital Signs: BP: 130/85 mmHg; P: 85; RR: 16; T : 98.8 oF; Wt : 130 lb ; Ht : 5’8″
• GU/Rect: Pelvic exam with pain and mucosal atrophy
• Neuro: Within normal limits (WNL)
• Cardiovascular: WNL
• Skin: Dry and itchy
Laboratory:
Tests Observed Values
Glucose (Glu) 110 mg/dL
Total Cholesterol (TC) 240 mg/dL
High density lipids (HDL) 37 mg/dL
Triglycerides (TRG) 250 mg/dL
Low density lipids (LDL) 160 mg/dL
Thyroid stimulating hormone (TSH) 3.49uIU/mL
Follicle stimulating hormone (FSH) 38 mIU/mL
Luteinizing hormone (LH) 38 mIU/mL
Estradiol level 15 pg/mL
Other tests:
• Pap smear and mammogram normal
• Negative pregnancy test
• Dual energy X-ray absorptiometry (DEXA) scan of lumbar spine and right femoral neck shows slight osteopenia (T scores of minus 1.6, and minus 2.4 respectfully)
Provide references with your explanations.
Submit your answers in a Microsoft Word document (maximum of 4 pages).
Submit your document to the W6: Assignment 2 Dropbox by Week 6, Day 4.
Cite any sources using the APA format on a separate page.
Assignment 2 Grading Criteria Maximum Points
Identified correctly and described the risk factors and medications contributing to the case. 15
Created appropriate, committed plan for the patient. 15
Wrote appropriate orders for the patient. 5
Used correct spelling, grammar, and professional vocabulary. Cited all sources using the APA format. 5
Total: 40
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