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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 came 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 trimestermiscarriage (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.