Case NURS MISC

CC – Night sweats, sleep problems, amenorrhea, G2P2 • Ovarian insufficiency / premature ovarian failure / craniopharyngioma? / prolactinemia / anovulation / pcos / turner / intrauterine adhesions /depression / drugtest!! / night terrors(psych) Diagnosis – Ectopic pregnancy Tests- FSH, PRL, cortisol-AM, TSH, lipid profile, MRI of head!!!/CT of head 2cc/10asc/3pmh/2sh Problem Statement: ( Demographic description – chief complaint – Hx and PE key findings – risk factors ) Dalisay Edwards is a 42 year old G2P2 woman presenting with Night sweats and sleep problems and Amenorrhea since the death of her mother 1 year ago. She has reported 5lbs weight gain. Physical exam is unremarkable. The patient denies recreational drug use, cigarette use, or drinking alcohol. CC: Dalisay Edwards is a 42 year old G2P2 woman presenting with Night sweats and sleep problems that started 1 year ago. HPI: She reported Night sweats and sleep problems since the sudden death of her mother 1 year ago. She also reports Amenorrhea which started “9 or 12 months ago” as well as 5lbs weight gain. Meds: none. PMH: Patient denies smoking, drinking, and recreational drug use. ROS: Only positive findings are seen in HPI Physical Exam: VS: Pulse – 80; BP – 122/62 (wide), RR – 12; T – 98.6F (37 C); SpO2 – 94% Physical exam unremarkable. ASSESSMENT/PLAN Test Results: • FSH: Consistent with post-menopausal levels • PRL: Normal • Cortisol AM: Normal • TSH: Normal • Free T4: normal • Lipid profile: Mild increased cholesterol, atherosclerosis ri ..............................................Continued...............................................