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Case #3.Monica.
History of Present Illness (HPI): Monica is a 43-year-old Africa
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.
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