Reference no: EM134004095
Question
Chief Complaint
"Vaginal bleeding."
History of Present Illness
A 28-year-old woman presents to her PCP with a 3-day history of dizziness, fatigue, and headache. She is mother of two girls, ages 5 and 2. She and her husband want another child, hopefully a boy, and have planned accordingly. She missed her last period and suspects she is pregnant; a home pregnancy test last week was positive. Until 3 days ago, she felt fine, other than some fatigue and mild nausea. Over the last 2 days, she began experiencing abdominal cramping and irregular vaginal bleeding. She points to both lower and upper quadrants as the main location of the pain. She describes her abdominal pain as 7 of 10. She has not used over-the-counter pain medication because she wants to avoid medication if pregnant. Additionally, she states, "When changing positions, I get lightheaded." When the PCP asks about her bleeding, she states she has had similar bleeding during her other pregnancies. "All my pregnancies are like that, it's normal."
Review of Systems
A ROS is positive for fatigue, nausea, abdominal pain, and vaginal bleeding. The patient reports headache and dizziness. The ROS is negative for fever, chills, vomiting, diarrhea, constipation, shortness of breath, or chest pain.
Relevant History
The patient's medical history is significant for cholecystectomy (age 27) and chlamydia infection (age 17). Her social history includes drinking one glass of wine per weekend since age 18. She had a few male sex partners prior to her marriage. She lives with her husband and children and describes her marriage as happy. Both children were full-term babies and the pregnancies were normal. Her family history is unknown as she was adopted.
Allergies
No known drug allergies; no known food allergies.
Medications
None.
Physical Examination
Vitals: T 37°C (98.6°F), P 70, R 19, BP 130/80, WT 78.7 kg (173.5 lbs), HT 167.6 cm (66 in.), BMI 28.
General: Appears anxious and fatigued, mild acute distress.
Skin, Hair, and Nails: No rash, skin warm and dry. No abnormal findings with hair or nails.
Lungs: Clear to auscultation bilaterally, good air movement throughout.
Heart: RRR, without murmur or gallop.
Abdomen: Abdomen was soft, non-distended, and moderately tender; generalized.
Neurologic: A&O×3, cranial nerves II to XII grossly intact.
Clinical Discussion Questions
1. What is the differential diagnosis?
2. What is the most likely diagnosis? Why?
3. Demonstrate your understanding about the pathophysiology in regard to the most likely diagnosis.
4. Should tests/imaging studies be ordered? Which ones? Why? Think about tests/imaging beyond the primary care setting as well.
5. What are the next appropriate steps in management?
6. Demonstrate your understanding about the most common location of the diagnosis, risk factors, and treatment options.
7. Provide references for your responses.
8. What is the appropriate patient education for this case?
9. If not managed appropriately, what is/are the medical/legal concern(s) that may arise?
10. Think about interprofessional collaboration for this case. Provide a list of specialties or other disciplines and indicate what contribution these professionals might make to managing the patient.
11. What would your communication style/approach be with this patient?
12. If a patient is distressed by the diagnosis, what might offer support?