22-year old obese female
In this task, a 22-year-old girl with an irregular menstrual cycle and overweight is trying to get pregnant and has been unsuccessful for 18 months. Questions to ask:
- Have you been seen by another doctor? What is your medical history?
- You have irregular menses, what is your cycle?
- Have you taken any hormonal medications? Which?
- Are you currently taking any medications?
- What is your weight at the time of pregnancy planning?
- Has your partner been tested and seen by a urologist?
- Did your female relatives have problems with fertilization? Which ones?
Evaluation in SOAP format
Subjective
- Previous medical history (obesity, hormonal disorders)
- Relatives medical history
- Partner’s medical history
Objective
- Pass a set of tests for the presence of hormonal disorders: thyroid hormones, progesterone, free testosterone, prolactin, estradiol (Reid, 2016).
- Gynecologist consultation
- Urologist consultation
- Endocrinologist consultation
Assessment
- Differential diagnosis:
- Hormonal disorders
- Pertinent positive: Heavy weight, irregular menstrual cycle
- Pertinent negative: N/A
- Diabetes mellitus
- Pertinent positive: Increased appetite, constant desire to eat sweets
- Pertinent negative: High weight throughout life, no metallic taste in the mouth
- Male infertility
- Pertinent positive: Pregnancy does not occur
- Pertinent negative: Spermogram is normal
Working Diagnosis: Hormonal Disorders
(The diagnosis was made on the basis of an irregular menstrual cycle, increased weight, and the partner’s health problems were excluded).
Plan
- Goals of treatment: The patient needs to reduce weight through diet and physical activity. Moreover, it is necessary to restore the hormonal background and lead the body to a regular cycle of menstruation.
- Education: The patient needs to be explained that it is necessary to go a long way to get pregnant, but it is essential to start now not to miss the period of fertility. In order to restore the hormonal background, she needs to take certain pharmacological drugs, as well as follow a diet and start leading an active lifestyle.
- Diet: it is necessary to create a food plan that will take into account the body’s daily needs in proteins, fats, and carbohydrates. In addition, this meal plan should be made taking into account the average daily intake of calories and sugar. The most suitable type of food will be chicken meat, grains, vegetables, and fruits.
- Physical activity: Daily physical activity will help you lose weight more effectively and maintain the overall health of the body. Every day, it is recommended to take 10,000 steps and three times a week to visit the sports field and cardio equipment.
- Vitamins: it is necessary to give blood for analysis in order to determine what vitamins the body lacks.
- Pharmacotherapy: “Menstrual-cycle dependent medication dosing may be better calculated by clinical response time than the drug’s pharmacokinetic properties” (Yum et al., 2019). Huizen (2020) recommends using ginseng and mac as dietary supplements, which are also over-the-counter medications. As medications that help restore the hormonal background, she recommends Clomiphene and Letrozole (Huizen, 2020). The dosage is prescribed individually, based on the tests.
- Age-appropriate preventive care: Since the patient is only 22 years old, sports and healthy nutrition will be preventive measures, not only in family planning, but also in the issue of other diseases.
In conclusion, the patient must pass general and biochemical blood tests, pass hormone tests, as well as tests for sex hormones. Moreover, it is necessary to start physical training, activity during the day, and diet, excluding sweets. When the results of the tests are received, she will be assigned a specific range of medications and vitamins that will complement the treatment at the next visit. When taking medications and maintaining a healthy lifestyle, the patient needs to record changes in the menstrual cycle. In the future, this will help to adjust the treatment and select the most appropriate one.
References
Huizen, J. (2020). What to know about hormonal imbalances. Medical News Today. Web.
Reid, R. (2016). International journal of women’s health and wellness: A pragmatic approach to hormonal testing in the assessment of disorders of female reproduction. International Journal of Women’s Health and Wellness, 2(3), 2-6.
Yum, S.K., Yum, S.Y. & Kim, T. (2019). The problem of medicating women like the men: conceptual discussion of menstrual cycle-dependent psychopharmacology. Transl Clin Pharmacol, 27(4), 127-133. Web.