NRNP-6552 - ADVANCED NURSE PRACTICE IN REPRODUCTIVE HEALTH CARE | WALDEN
UNIVERSITY
NRNP 6552: CASE STUDY - Week 4 Missing Period
Latest Discussions.
Case Study: Missed Period
Juanita Morales is a 47-year-old G5. P5 LC 6, Hispanic female who presents to the office complaining of
lower abdominal cramping, and urinary leakage for past day. She states the abdominal cramping,
suprapubic, started several hours ago, is sharp, intermittent, and getting more frequent and painful.
She tried Motrin but states it did not help. She had a UTI years ago and it was like this, except the
incontinence. She has been more tired for the past several months. She relates she stopped getting her
period about 8-12 months ago, and relates her menopause was easy. She relates no medical or surgical
history. She has no known drug allergies and takes no medications. Social history is negative for
alcohol, tobacco, and recreational drugs. Her last exam was several years ago.
Vital signs: temperature 99.1, BP 140/ 82, pulse 88, respirations 12. Height is 5’ and
weight 235 lbs. (BMI 45.89). A clean catch urine was obtained, and the urine dipstick showed SG 1.010,
trace blood, neg nitrates, neg leukocytes, negative glucose, 3+
protein. She thinks that maybe she had some vaginal spotting several days ago, but nothing since.
Pt relates that she has had some constipation, and increased gas for past several months. She was
using NFP for contraception prior to her stopping her period. No other urinary symptoms reported.
Update:
, Week 4 Case Study Discussion Main Post
Episodic/Focused SOAP Note
Patient Information:
JM, 47, Female, Hispanic
S.
CC (chief complaint): lower abdominal cramping, and urinary leakage
HPI: 47-year-old Hispanic female presents to the office for complaints of lower abdominal
cramping and urinary leakage. The abdominal pain is located suprapubic, and the onset was
several hours ago. She characterized the pain as sharp, intermittent, and getting more frequent
and painful. Incontinence is associated with the abdominal pain. She has taken Motrin but reports
it does not help. Dosage, frequency, and length of time Motrin has been used is unknown. Pain
severity was not rated on 0-10 scale.
Allergies: NKDA
Medications: No daily medications; Motrin for pain (dose unknown)
PMHx: immunization history unknown; history of UTI, menopause, constipation; denies
surgeries
Soc & Substance Hx: denies use of alcohol, tobacco, and recreational drugs; no health
promotion information available
Fam Hx: family history information is not available
Surgical Hx: Denies previous surgical procedures.
Mental Hx: mental health history is not available
Violence Hx: safety concerns/issues information is not available
Reproductive Hx: date of last menstrual period – 8-12 months ago, G5 P5 LC 6,
nursing/lactating – no, contraceptive use – previously used NFP prior to her period stopping,
types of intercourse – information unavailable, gender sexual preference – information
unavailable, sexual concerns – none reported
ROS:
UNIVERSITY
NRNP 6552: CASE STUDY - Week 4 Missing Period
Latest Discussions.
Case Study: Missed Period
Juanita Morales is a 47-year-old G5. P5 LC 6, Hispanic female who presents to the office complaining of
lower abdominal cramping, and urinary leakage for past day. She states the abdominal cramping,
suprapubic, started several hours ago, is sharp, intermittent, and getting more frequent and painful.
She tried Motrin but states it did not help. She had a UTI years ago and it was like this, except the
incontinence. She has been more tired for the past several months. She relates she stopped getting her
period about 8-12 months ago, and relates her menopause was easy. She relates no medical or surgical
history. She has no known drug allergies and takes no medications. Social history is negative for
alcohol, tobacco, and recreational drugs. Her last exam was several years ago.
Vital signs: temperature 99.1, BP 140/ 82, pulse 88, respirations 12. Height is 5’ and
weight 235 lbs. (BMI 45.89). A clean catch urine was obtained, and the urine dipstick showed SG 1.010,
trace blood, neg nitrates, neg leukocytes, negative glucose, 3+
protein. She thinks that maybe she had some vaginal spotting several days ago, but nothing since.
Pt relates that she has had some constipation, and increased gas for past several months. She was
using NFP for contraception prior to her stopping her period. No other urinary symptoms reported.
Update:
, Week 4 Case Study Discussion Main Post
Episodic/Focused SOAP Note
Patient Information:
JM, 47, Female, Hispanic
S.
CC (chief complaint): lower abdominal cramping, and urinary leakage
HPI: 47-year-old Hispanic female presents to the office for complaints of lower abdominal
cramping and urinary leakage. The abdominal pain is located suprapubic, and the onset was
several hours ago. She characterized the pain as sharp, intermittent, and getting more frequent
and painful. Incontinence is associated with the abdominal pain. She has taken Motrin but reports
it does not help. Dosage, frequency, and length of time Motrin has been used is unknown. Pain
severity was not rated on 0-10 scale.
Allergies: NKDA
Medications: No daily medications; Motrin for pain (dose unknown)
PMHx: immunization history unknown; history of UTI, menopause, constipation; denies
surgeries
Soc & Substance Hx: denies use of alcohol, tobacco, and recreational drugs; no health
promotion information available
Fam Hx: family history information is not available
Surgical Hx: Denies previous surgical procedures.
Mental Hx: mental health history is not available
Violence Hx: safety concerns/issues information is not available
Reproductive Hx: date of last menstrual period – 8-12 months ago, G5 P5 LC 6,
nursing/lactating – no, contraceptive use – previously used NFP prior to her period stopping,
types of intercourse – information unavailable, gender sexual preference – information
unavailable, sexual concerns – none reported
ROS:
