Case #3.Monica.
History of Present Illness (HPI): Monica is a 43–year–old African– American G3P2102. She is currently
separated from her husband of 20 years and is working full–time as a legal secretary. About 8 months
ago, Monica started having irregular periods with heavier than usual flow until she stopped having
periods or any vaginal bleeding about 3 months ago. She is currently recovering from a “stomach flu”
however, she reports daily nausea, vomiting, bloating and decreased appetite over the past 3 weeks.
She is worried because she has gained 12 pounds over the last 3 months “due to menopause”. She
comes to the clinic today to discuss menopause symptoms and hormone replacement therapy.
Prior medical history: Hypertension (2010)– well controlled on current antihypertensive
Prior surgical history: Cholecystectomy (2015)
Current medications: Lisinopril 10mg daily. Allergies: None
OB– GYN History: NSVD x 2 (2015, 2019) healthy female 6lb 8oz; healthy female 7lbs 6oz. First trimester
miscarriage (9 weeks) in 2014. Menarche age 15, cycle length–7 days– frequency every 28 days– 5–6 pads
per day. No history of sexually transmitted infections (STDs). No history of abnormal pap (last pap 2
years ago).
LMP: Approximately 3 months ago. Contraception history: Condoms; past use of oral contraceptives.
Social history: Lives with her elderly father, 2 daughters. Separated from her husband for 6 months.
Family history: Mother deceased (age 60)– breast cancer. Father alive (age 70)– hypertension.
Review of Systems (ROS): Unremarkable with exception of as noted in HPI.
Physical Exam (PE)
VS: BP: 130/78, P: 78, RR: 18, T: 36.1 Weight: 152 lbs.
Physical exam is unremarkable with exception of a palpable 12– 14 weeks size uterus on bimanual. You
check a for a fetal heartbeat and obtain a heart tone of 145 via doppler. The intake nurse reports that a
urine pregnancy test came back positive.
Monica is in disbelief.
Support your case study using 5 APA Citation within last 5 years Nursing background.
