Name:  

 Pt. Encounter Number:

Date: 

Age: 29

Sex: 

SUBJECTIVE

CC:  

“I’m here because of menopausal changes to my periods. Which I’m concerned may make me impotent and never get pregnant.” 

HPI:  

The patient is a 29-year-old female presenting with concerns about irregular menstruation and difficulty conceiving. She reports her periods have been irregular for the past 11 months after discontinuing birth control. She stopped the birth control pill to try to conceive. After discontinuation, her first period was absent for 8 weeks, followed by infrequent cycles every 2-3 months. Each period is described as light, lasting only 2-3 days. She reports a history of irregular periods starting at age 13, which led to her being placed on birth control. She also mentions a noticeable increase in facial hair (particularly on the chin and upper lip), which she waxes frequently, as well as increased acne and darkening of the skin under her arms and in the groin area. She has gained approximately 20 pounds over the past two years. The patient reports trying a progesterone pill 6 months ago, but it did not regulate her cycle.

Medications: None currently, previously used oral contraceptives and progesterone pills for menstrual regulation. 

Allergies: No known drug allergies.

Medication Intolerances: None.

Past Medical History: Menstrual irregularities since menarche at age 13.

  • Previous use of birth control to regulate cycles.

 Chronic Illnesses/Major traumas: None reported.

 Hospitalizations/Surgeries

  • None. 

Family History

  • No history of diabetes, hypertension, heart disease, or thyroid problems in immediate family.
  • No known family history of reproductive health issues. 

Social History

  • Non-smoker, no alcohol use or illicit drug use.
  • Lives with partner, employed as a teacher.
  • No safety concerns. 

ROS Student to ask each of these questions to the patient: “Have you had any…..”

General: Weight gain of 20 lbs over the past two years. No fever, fatigue, or night sweats. 

Cardiovascular: No chest pain, palpitations, or edema. 

Skin: Increased acne, darkened skin in axillae and groin. No rashes or lesions noted. 

Respiratory: No cough, dyspnea, or wheezing. 

Eyes: No visual changes, corrective lenses not needed. 

Gastrointestinal: No abdominal pain, nausea, vomiting, or diarrhea. 

Ears: No hearing loss, ear pain, or ringing in the ears. 

Genitourinary/Gynecological: Irregular menstrual cycles, light periods, attempting conception. Last pap was two years ago, normal results. No vaginal discharge. No history of sexually transmitted diseases (STDs). 

Nose/Mouth/Throat: No sinus problems or throat pain 

Musculoskeletal: No joint pain, back


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