Visit · Hormone protocol week 6 review
Today · 10:00 · Dr Naledi Sithole · 45 minutes · Consult Room 1
Vitals · captured by Sister Lerato 09:48
EditWeight
71.8kg
−0.4 vs last
BP
118/76mmHg
Optimised
HR
62bpm
Resting
Sleep
7.4hrs
Self-report
AI scribe · listening
CONSENT v1.0 · 12 Apr 2026
Recording locally · transcribing · drafting SOAP from conversation. Will surface ICD-10 + tariff candidates after sign-off prompt. 06:14 elapsed.
Hormonal protocolSleep improvingMild breast tenderness
S Subjective
O Objective
A Assessment
P Plan
Diagnosis + billing codes
Primary ICD-10
N95.1 — Menopausal and female climacteric states
Secondary ICD-10
G47.00 — Insomnia, unspecified
E02 — Subclinical iodine-deficiency hypothyroidism
E78.2 — Mixed hyperlipidaemia
Tariff codes
0192 — Established patient consultation, intermediate
1235 — Counselling on chronic disease, 30 min
Pre-flight check
Discovery KeyCare Plus · pre-flight passed · ICD/tariff congruent · member active · benefit available · estimated payout $79 · patient liability $24 (non-PMB co-pay).
Orders generated this visit
Lab order
Pending
Lancet Pathology · routine · fasting required
Tests: Hormone panel (E2, FSH, LH, Prog) · TSH, FT4, FT3 · Lipid panel · HbA1c
ICD motivation: N95.1
Sent to patient portal as printable referral.
Tests: Hormone panel (E2, FSH, LH, Prog) · TSH, FT4, FT3 · Lipid panel · HbA1c
ICD motivation: N95.1
Sent to patient portal as printable referral.
Repeat script
Issued
Estradiol patch 50mcg · 2x weekly · 90-day supply
Progesterone micronised 100mg · nightly cycle 1-25 · 90-day
eScript · sent to patient portal · auto-collected at Dis-Chem Stellenbosch.
Progesterone micronised 100mg · nightly cycle 1-25 · 90-day
eScript · sent to patient portal · auto-collected at Dis-Chem Stellenbosch.
Follow-up
Booked
30 May 2026 · 10:00 · 45 min
Hormone protocol week 12 review
Patient calendar invite + portal reminder set · 48hr + 2hr SMS armed.
Hormone protocol week 12 review
Patient calendar invite + portal reminder set · 48hr + 2hr SMS armed.
Patient handout · auto-drafted
Week 6 wins + week 7 micro-targets
What we noticed today: Sleep is back to 7+ hours, energy is steady through the workday for the first time in 14 months, and the brain fog is mostly gone in the mornings. The mild breast tenderness is normal — it usually settles over the next two weeks, but flag if it doesn't.
Keep doing: Estradiol patch (twice a week, same days), progesterone capsule each night, magnesium before bed, supplements with breakfast.
One small adjustment this week: A third Pilates session. The body is asking for it now that the energy is there.
Coming up: Repeat blood panel before our next visit on 30 May — Layla session next Thursday, supplements protocol stays the same.