Case Study: 16-Year-Old G1P0 with a Missed Period (Women’s Health)

Case #1. Teresa.

History of Present Illness (HPI): Teresa is a 34-year-old Hispanic G2P2002 . She presents to your office today at 10-weeks post-partum (PP) for her 6-week PP check. She underwent a C-section for failure to progress following a 20-hour labor with Pitocin augmentation. She was discharged from the hospital on

day 2 post-partum without complications. Teresa has had difficulty with breast feeding due to discomfort in her suture line and terrible pain in her right breast since her discharge from the hospital. She reports occasional chills- she has not measured her temperature at home. Teresa was seen by the lactation consultant while in the hospital but “nothing is working” and her son “cries all the time”. She is afraid to feed her son formula as her mother-in-law wants her to “keep trying to breastfeed”. Teresa tells you she feels as if she has failed her son- “it was so easy with my first baby, I know my husband thinks I am a bad mother”.

Prior medical history: None. Prior surgical history: Appendectomy (2000)

Current medications: Prenatal vitamins, stool softener. Allergies: None

OB- GYN History: NSVD (2019) healthy female 7lb 10oz; C-section healthy male 8 lbs. 8 oz as per HPI.

Menarche age 12, cycle length- 5 days- frequency every 28 days- 4-5 tampons per day. No history of sexually transmitted infections (STDs). History of abnormal pap smear in 2019 which was followed by a normal colposcopy. Last pap (during recent prenatal care) reported normal. HIV negative.

LMP: First PP menstrual cycle last week. Has not resumed sexual activity PP. Contraception history: Oral contraceptives, condoms.

Social history: Lives with husband, mother- in- law, and children. Stay at home mom. Denies EtOH or recreational drug use, never smoker. Her family speaks Spanish at home; she is fluent in English.

Family history: Unremarkable.

Review of Systems (ROS): Negative except as noted in HPI.

Physical Exam (PE)

VS: BP: 110/70, P: 90, RR: 18, T: 38.4, Weight: 132 lbs.

Teresa’s C-section suture line is healing well without erythema or tenderness. No vaginal discharge or lesions, no cervical motion tenderness (CMT), uterus normal size firm and non-tender. On breast exam, you do note an erythematous, swollen, and painful area to the right breast. Her physical exam is otherwise unremarkable.

Case #4. Laura.

History of Present Illness (HPI): Laura is a 16-year-old Caucasian G1P0. She presents to your office after missing her second period. She is “worried” as she “always gets her period on time”. She is in high school- about to enter the 11th grade. She lives with her grandmother and 2 older siblings. Her urine

pregnancy test in clinic today is positive.

Laura is sexually active with her boyfriend; they do not use condoms. He “pulls out” as birth control. She reports being treated at the health department for chlamydia and gonorrhea earlier this year. She thinks her boyfriend was treated but he is not answering her calls since she told him about the missed

periods a few weeks ago. She reports daily nausea, vomiting and dysuria for the past 2 weeks.

Prior medical history: None. Prior surgical history: None

Current medications: None. Allergies: None

OB- GYN History: Menarche age 12, cycle length-7 days- frequency every 30 days- 2 tampons per day.

History of chlamydia and gonorrhea (GC) in the past year. Last pap reported normal at the time of

chlamydia/ GC diagnosis. Has not received Human Papillomavirus (HPV) vaccine.

LMP: Approximately 2 months ago. Contraception history: Withdrawal

Social history: Lives with her grandmother, siblings. Denies EtOH or recreational drug use. Currently

smoking 1 pack of cigarettes/ day

Family history: Mother deceased at age 42- drug overdose. Father unknown.

Review of Systems (ROS): Unremarkable with exception of as noted in HPI.

Physical Exam (PE)

VS: BP: 110/68, P: 80, RR: 18, T: 37.1 Weight: 110 lbs. (states usual weight 120 lbs.).

Physical exam is unremarkable with exception of a cloudy, yellow mucoid cervical discharge on speculum

exam; friable appearance of the cervix with cervical motion tenderness (CMT). You palpate an 8-week

size uterus on bimanual.

Laura’s urine reveals 2+ ketones, 2+ nitrates, and 3+ leukocytes.

Case 5: Denise.

Denise is a 30-year-old Black female G0 with a history of seizure disorder who presents to clinic for her annual well visit. She is excited to tell you that she is getting married in 2 months and they are planning to start a family “right away”. Denise went to see her gynecologist last month who told her she was “young and healthy- not to worry, everything will work out fine”. No labs were done at the gyn visit; she hasn’t started prenatal vitamins. She comes to see you today as she “wants to be sure that she is up to date on everything she needs” before the wedding.

Prior medical history: Seizure disorder (diagnosed at age 18). Prior surgical history: None

Current medications: Levetiracetam 500mg 2 times a day. Allergies: None

Reports she believes she has had all childhood vaccinations. Has not received COVID or influenza vaccines. She is not sure about Hepatitis B or Tdap.

OB- GYN History: G0. Menarche age 14, cycle length-5 days- frequency every 28 days- 2-3 pads per day. No history of sexually transmitted infection. Last PAP 2020, no history of abnormal PAP. Has not received Human Papillomavirus (HPV) vaccine. Her only sexual partner is her current fiancé (male). LMP was approximately 2 weeks ago. Contraception history: Condoms.

Social history: Sixth grade teacher. Lives with her fiancé. Denies EtOH or recreational drug use. Has never smoked cigarettes or vaped.

Family history: Mother (age 56) alive and well. Father deceased at age 50 from lung cancer (smoker). Sister aged 21- healthy. Maternal grandmother alive age 88 (hysterectomy for fibroid uterus). Maternal grandfather deceased age 78 (unknown cause). Paternal grandparents- unknown.

Review of Systems (ROS).

Constitutional: No Weight Change, No Fever, No Chills, No Night Sweats, No Fatigue, No Malaise

ENT/Mouth: No Hearing Changes, No Ear Pain, No Nasal Congestion, No Sinus Pain, No Hoarseness, No sore throat, No Rhinorrhea, No Swallowing Difficulty

Eyes: No Eye Pain, No Swelling, No Redness, No Foreign Body, No Discharge, No Vision Changes

Cardiovascular: No Chest Pain, No SOB, No Dyspnea on Exertion, No Orthopnea, No Claudication, No Edema, No Palpitations

Respiratory: No Cough, No Sputum, No Wheezing, No Smoke Exposure, No Dyspnea

Gastrointestinal: No Nausea, No Vomiting, No Diarrhea, Occasional Constipation (managed with diet), No Pain, No Heartburn, No Anorexia, No Dysphagia, No Hematochezia, No Melena, No Flatulence, No Jaundice

Genitourinary: No Dysmenorrhea, No Abnormal Vaginal Bleeding, No Dyspareunia, No Dysuria, No Urinary Frequency, No Hematuria, No Urinary Incontinence, No Urgency, No Flank Pain, No Urinary Flow Changes, No Hesitancy

Musculoskeletal: No Arthralgias, No Myalgias, No Joint Swelling, No Joint Stiffness, No Back Pain, No Neck Pain, No Injury History

Skin: No Skin Lesions, No Pruritis, No Hair Changes, No Breast/Skin Changes, No Nipple Discharge

Neuro: No Weakness, No Numbness, No Paresthesia, No Loss of Consciousness, No Syncope, No Dizziness, No Headache, No Coordination Changes. Last reported seizure was 10 years ago. Followed by neurologist- last seen in 2023.

Psych: No Anxiety/Panic, No Depression, No Insomnia. No Memory Changes. Denies Violence/Abuse, No Eating Concerns

Heme/Lymph: No Bruising, No Bleeding, No Transfusion History, No Lymphadenopathy

Endocrine: No Polyuria, No Polydipsia, No Temperature Intolerance

Physical Exam (PE).

VS: BP: 130/84, P: 80, RR: 18, T: 37.1, Weight: 118 lbs. BMI 19.0

General: Awake, alert, and oriented. No acute distress. Well developed, hydrated, and nourished. Appears stated age.

Skin: Skin in warm, dry, and intact without rashes or lesions. Appropriate color for ethnicity. Nailbeds pink with no cyanosis or clubbing.

Head: The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Hair is of normal texture and evenly distributed.

Eyes: Conjunctivae are clear without exudates or hemorrhage. Sclera is non-icteric. No signs of nystagmus. Eyelids are normal in appearance without swelling or lesions.

Ears: The external ear and ear canal are non-tender and without swelling.

Laura is a 16-year-old Caucasian G1P0. She presents to your office after missing her second period.