History of Present Problem:
Anne Jones is a 17-year-old Caucasian teenager who thinks she may be pregnant because she has missed two periods.
Her last menstrual period, she thinks, was about one month ago. She states
...
History of Present Problem:
Anne Jones is a 17-year-old Caucasian teenager who thinks she may be pregnant because she has missed two periods.
Her last menstrual period, she thinks, was about one month ago. She states she had a little bit of spotting last week but
didn’t have a “full period”. She complains of her breasts being tender, swollen, frequent urination, and nausea in the
morning. This is her first office visit and she is not sure why she feels so crummy but suspects she might be pregnant.
Her urine pregnancy test is positive. Her primary care provider orders a prenatal lab panel and a urinalysis.
Personal/Social History:
Anne is a senior in high school who stands on her feet while working at McDonalds after school. She drinks six colas
daily, denies alcohol use, and does not smoke. She takes no medications except for occasional acetaminophen for
headaches and ibuprofen for menstrual cramps. Anne is 5’4” (160 cm) and weighs about 105 lbs. (47.7 kg) according to
Anne. A 24-hour recall nutrition history reveals a typical day’s diet: breakfast- pop tart and can of cola; Lunch- a slice of
pizza, chocolate chip cookie, can of cola; Dinner- fried chicken, green beans, biscuit, can of cola; snacks, including
cookies and can of cola. She broke up last week with her boyfriend, and he is not aware she might be pregnant. She wants
to keep the baby but has not told her parents.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
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