The Pregnant Woman

Case Study

CHIEF COMPLAINT: "My periods are irregular."

History of Present Illness:

A 16-year-old high school junior presents to the clinic for evaluation of irregular menses. Her periods were regular until 4 months ago. She first skipped a period then had some light spotting, which lasted for 2 or 3 days, and then it went away. Last week, the spotting returned and lasted 1 day.

She has noticed increased tiredness and was nauseated for a few weeks, but it went away a couple of weeks ago. She denies any fever or chills. She denies abdominal pain or vaginal discharge. She has noticed some intermittent low back pain. She has not used any over-the-counter medications to treat the pain.

She states that her menses started at age 13; the menses last 5 days on average. She has never been pregnant. She is sexually active and is in a monogamous relationship. She uses oral contraceptives for birth control; her partner uses a condom.

She is healthy; she has never taken any medications on a regular basis. She does not smoke; she drinks alcohol on the weekends with friends, but no more than 1 or 2 drinks over the weekend; she has never used illicit drugs.

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