Case Study:

C.S. is a 19 year old female client who presents to the clinic with an acute upper respiratory infection.  She is 15 weeks pregnant and has not established prenatal care.  This is her second pregnancy.  To date she has had no weight gain and takes phenytoin for a seizure disorder.

History

C.S. is a single mother.  She has a 16 month old son at home. She has a high school diploma.  She is not working. The father of her son is not involved nor is the father of the baby.  She does not have a great support network in place.  Ms. S is a 1 ppd smoker and has a poor diet.  She drinks several cups of coffee and cola per day.  She sleeps an average of 4 5 hours per night.  Her stress level is high as result of financial struggles and single parenting.   She denies any other complications or prolonged illnesses or injuries. She denies any alcohol or illicit drug use.

Questions

  1. Of the following, what are C.Ss risk factors:
    • Substance use/abuse
    • Stress
    • Sedentary lifestyle and lack of exercise and personal fitness
    • Exposure to intimate partner, family, or stranger violence?
  • Provide a rationale for your selections.
  1. What additional questions should be asked to gain an understanding of the present illness?
  2. What would be included in the review of systems?
  3. Discuss the elements of an abbreviated physical examination.
  4. List 2 community resources in your area to which you could refer Ms. S.

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