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Case 5.4 Missed Periods

By Vera Borkowski, MSN, APRN, FNP‐C

SUBJECTIVE

Genevieve is a 17‐year‐old female who came to the clinic requesting a pregnancy test “because I haven’t gotten my period and it is 3 weeks late.” Genny reports that she normally gets her period every month and uses a period tracker, and is able to report her last period’s exact start date 55 days ago. She reports that her last period was of normal duration and flow. She says she had multiple occurrences of unprotected sex with her boyfriend of the same age in the past month, and has not taken any pregnancy tests at home. Per her chart and report, Genny has not previously been screened for sexually transmitted infections (STIs). She states, “We lost our virginity to each other a few months ago, so I don’t think he has any STIs.” The clinician asks her if she wants to get pregnant and Genny states, “Not really, but my boyfriend doesn’t like using condoms.” Genny has not told her family she is sexually active, and is requesting that this visit be confidential. She is not on any type of birth control, “because I’m afraid if I ask, my mom will know I’m having sex.”

Past medical history: Obesity.

Family history: No pertinent family history.

Social history: Denies substances, alcohol, or vaping use. Scores negative on PHQ‐2 screening. Reports only vaginal intercourse in a monogamous relationship. 1 sexual partner.

Medications: None.

Allergies: NKDA

OBJECTIVE

Weight: 210 lbs; height: 65 in; BMI: 34.9; BP: 110/70; PHQ‐2: 0 Negative.

General: Pleasant, well developed, obese, in no acute distress.

Respiratory: CTA bilaterally, no wheezes, rales, or rhonchi.

Cardiac: RRR, S1 S2 normal with no murmurs, rubs, or gallops.

Breast: Tanner V symmetrical.

Abdomen: Bowel sounds present, abdomen soft, nontender, nondistended, with no hepatosplenomegaly. Exam limited by adipose habitus.

Genitourinary: Pubic hair normal; Tanner V normal female; mucosa pale and pink, no lesions; no lymphadenopathy, discharge, or odor.

CRITICAL THINKING

1 Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Urine HCG___HIV testing___STI screening___Pap smear___Urine dipstick

2 Why is it important to ask Genny what she feels her boyfriend would want if she were pregnant?

3 What additional questions should Genny be asked?

4 If Genny is pregnant today, what are her options?

5 Should contraception be prescribed today?

6 What health education should be provided to this patient?

7 Are there technologies available to assist Genny in managing or understanding her menstruation?