Chief Complaint: “My vagina has been dry and it is burns sometimes”

History of Present Illness: This is a 49-year old Caucasian female who recently has been diagnosed as having menopause and complaining of vagina dryness and burning. This problem started about 2 months ago about 3 months after being confirmed as being in menopause. Per patient it has been difficult to have sex due to the fact that her “vagina is so dry that it hurts me and my husband as well”. Patient is not sure about what is going and is arriving in clinic to find help.

Review of systems:
• Constitutional: no acute distress and denies fever, chills, night sweats, weight loss fatigue or change in appetite.
• Neuro: denies headache, muscle weakness, seizure, dizziness or …show more content…
In this case, vaginal pH would be above normal postmenopausal usually pH exceeding 5 which is a positive indication of atrophic vaginitis (Bachmann & Nevadunsky, 2000). In addition, labs also confirm atrophic vaginitis. This patient is in menopause and levels of estrogen would indicate not only menopause but confirm the diagnosis of atrophic vaginitis. Serum hormone concentration would show levels of circulating estrogen at less than or equal to 4.5 (Bachmann & Nevadunsky, 2000). The labs alone confirm the diagnosis of atrophic vaginitis especially given the fact the patient is confirmed to be in menopause and atrophic vaginitis. A chlamydia and gonorrhea swab was obtained and was …show more content…
After diagnosis was confirmed; the patient is merely not there to accept the solution or treatment plan but to agree to it as well. This particular patient was concerned about taking any prescribed medication that can assist her condition due to side effects that accompany medication regimen and the reliance of prescription medication for her condition. However, the patient was more willing to incorporate over the counter medications and so it was agreed upon to initiate a vaginal moisturizer as opposed to estrogen therapy. In this clinical encounter, the provider and myself along with the patient helped develop the plan of care for this patient. Other alternatives were considered in case the current treatment plan did not work for the