Menopause Health Assessment
Main concerns:
* Hot flushes
* Difficulty sleeping
* Vaginal dryness
LMP and menstrual history:
* LMP was 6 months ago, periods previously regular, now infrequent.
Menopause or perimenopause symptoms:
[x] Vasomotor
[x] Psychological
[x] Musculoskeletal
[x] Genitourinary
[x] Sexual
[ ] Other
Past medical history:
* Nil significant
Past medical history – contraception:
* Patient has had a Mirena coil fitted for 5 years, removed 6 months ago.
Past medical history – cardiovascular:
* Nil significant
Past medical history – cancer:
* Nil significant
Past medical history – vte:
* Nil significant
Past medical history – osteoporosis:
* Nil significant
Past medical history – migraine:
* Nil significant
Family history:
* Mother with breast cancer diagnosed at age 65.
Family history – vte:
* Nil significant
Family history – cardiovascular disease:
* Father with hypertension.
Family history – osteoporosis:
* Nil significant
Health screening history:
[x] Breast screening – last mammogram
[x] Cervical screening
[ ] Bowel cancer screening
[ ] Bone density
[x] Cardiovascular risk assessment
Social history:
* Smokes 5 cigarettes per day.
* Drinks 1-2 units of alcohol per week.
* Eats a balanced diet.
* Exercises 3 times per week.
Examination:
* Height: 165cm
* Weight: 75kg
* BMI: 27.5
* Blood pressure: 135/85 mmHg
Plan:
* Discussed lifestyle modifications, including regular exercise and smoking cessation.
* Discussed HRT options, patient keen to try.
* Prescribed transdermal oestrogen and cyclical progesterone.
* Arrange follow-up appointment in 3 months to review symptoms and HRT effectiveness.
Menopause Health Assessment
Main concerns:
[main concerns] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
[lmp and menstrual history] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
[menopause or perimenopause symptoms] (Mark with "[x]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, and leave "[ ]" for information not explicitly mentioned. Do not omit any categories, even if nothing is reported.)
[ ] Vasomotor
[ ] Psychological
[ ] Musculoskeletal
[ ] Genitourinary
[ ] Sexual
[ ] Other
Past medical history:
[past medical history – gynaecological] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
[past medical history – contraception] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
[past medical history – cardiovascular] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
[past medical history – cancer] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
[past medical history – vte] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
[past medical history – osteoporosis] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
[past medical history – migraine] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Family history:
[family history – cancer] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
[family history – vte] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
[family history – cardiovascular disease] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
[family history – osteoporosis] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Health screening history:
[health screening history] (Mark with "[x]" if information is explicitly mentioned in the transcript, contextual notes, or clinical note, and leave "[ ]" for information not explicitly mentioned. Do not omit any categories, even if nothing is reported.)
[ ] Breast screening – last mammogram
[ ] Cervical screening
[ ] Bowel cancer screening
[ ] Bone density
[ ] Cardiovascular risk assessment
Social history:
[social history] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points. Include smoking, diet, alcohol, drug use, complementary therapies, and exercise.)
Examination:
[height] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
[weight] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
[bmi] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
[blood pressure] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
Plan:
[non-hormonal treatment plan] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
[hormonal treatment plan] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
[lifestyle advice or strategies] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
[follow-up arrangements] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)