HISTORY:
Hot flashes for
Severity:
Duration:
Episodes: times per
Worsening factors:
Alleviating factors: ,
, over ,
Last menstrual period: ago
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Breasts: -R: , -L:
Abdomen: , , ,
Pelvic: vulva , vagina , cervix , uterus , adnexa ,
Skin:
Extremities: , , cap refill , pulses ,
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , , , ,
- Urine: ,
- Benefits of hormone replacement therapy discussed: control of symptoms, decrease in osteoporosis, endometrial cancer, colon cancer, myocardial infarction, and overall mortality
- Risk of hormone replacement therapy discussed: breast cancer, stroke, venous thromboembolism, gallbladder disease
-
- unnecessary if no uterus
-
-
- Reassess medications that may contribute to hot flashes (SSRIs, SNRIs, TCAs, opioids, tamoxifen, raloxifene, aromatase inhibitors, GnRH agonists, GnRH antagonists, antiandrogens, corticosteroids, isoniazid, hydralazine, niacin, metronidazole)
- Avoid hot environments
- Avoid caffeine
- Avoid alcohol
- Avoid spicy foods
- Regular exercise
- Referral to endocrinologist
- Referral to gynecologist
- Follow-up in
- Return if hot flashes worsen, if new symptoms develop such as fever, chills, or weight loss