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With the above information, construct the patientâ€™s subjective data in a SOAP Note format.

She is a 5-year-old, post-menopausal woman G1 P1, presenting with an 8-month history of vasomotor symptoms. She averages 6 or more hot flashes per day and is frequently awakened by night sweats. She is complaining of decreased libido. She is concerned about the possibility of developing breast cancer. She has no family history of breast cancer. She is also concerned about the possible risk of developing Alzheimer’s disease.

OBJECTIVE DATA

She has an intact uterus. She reports no period for a year. She takes a multivitamin daily. Her mother and a maternal aunt had osteoporosis, and her mother has sustained a hip fracture. No family or personal history of breast cancer and has not had a breast biopsy.

ASSESSMENT

She is 5’7″ in height and weighs 126 lbs, for a body mass index (BMI) of 19.8 with a BMI of 19.8. She smoked 1 pack of cigarettes daily for 20 years.

How would you diagnose and treat vaginal atrophy? Vaginal atrophy is thinning, drying and inflammation of the vaginal walls that may occur when your body has less estrogen which occurs most often after menopause. Common symptoms are burning, itching, spotting and pain with sex. Vaginal atrophy can be diagnosed through symptoms and a pelvic exam to look at the vagina in the cervix. Vaginal atrophy during pelvic exam can present as a shortened or a narrow vagina, dryness, white discoloration, vulvar lesions or vulvar patch redness, lacerations near vaginal opening, and decrease size of labia.
Discuss general treatment of menopause and osteoporosis with hormones. Hormone replacement therapy (HRT) rapidly brings to normal the bone turnover, preserves bone mineral density (BMD) at all skeletal sites, leading to a significant reduction in vertebral and non-vertebral fractures which are associated with postmenopausal women. They are effective in the treatment of vasomotor symptoms, vaginal atrophy, and treatment of osteoporosis. HRT causes your estrogen levels to increase. This can help to prevent bone loss and reduce your risk of developing osteoporosis and of breaking bones.
How would you counsel this client? I would educate the patient about her symptoms related to postmenopausal syndrome. I would advise her to consider hormonal therapy to help manage her symptomâ€™s and encourage her to eat healthy. I would also advise her against cigarette smoking and encourage her to take multivitamin supplementation to prevent complications like osteoporosis and pathological fractures.
Include a discussion of bio-Identical hormones and compounding with saliva testing. Be sure to discuss what subjective/objective data you need before you prescribe. Saliva testing is a noninvasive way of assessing your patientâ€™s hormone balancing needs and is proving to be the most reliable medium for measuring hormone levels (Kells et al., 2009). Saliva testing represents only hormones actively delivered to receptors in the body. Saliva testing is more accurate and reliable than serum hormone level testing which reduces the risk of overdose and complications of hormone therapy (Kells et al., 2009).

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