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Pamela Flowers Case Study - CC: PELVIC PAIN - Complete Solution $7.48   Add to cart

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Pamela Flowers Case Study - CC: PELVIC PAIN - Complete Solution

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Pamela Flowers Case Study - CC: PELVIC PAIN - Complete Solution

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  • November 11, 2021
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  • 2021/2022
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PAMELA FLOWERS – OBGYN

CC: abnormal vaginal bleeding and LLQ pelvic pain
Gynecological exam shows tenderness and L- adnexal fullness (no mass) w/ enlarged + soft uterus.
Patient has history of irregular periods.


DDX

 Endometriosis

 tubo-ovarian abcess

 Pelvic inflammatory disease

 ovarian cyst

 ectopic pregnancy

 abortion

 ovarian torsion

 dysmenorrhea-primary

Problem Statement:

( Demographic description – chief complaint – Hx and PE key findings – risk factors )

She has a history of dysparenuria on her left side.




HPI: The vaginal bleeding and pain started 1 day prior. Patient also describes dyspareunia 1 week ago,
and has history of ‘irregular periods’

Meds: inhaler for asthma

PMH: Pap smear + gyn exam 8mo ago normal – treated for chlamydia infection 3 years ago.

SH: one current sexual partner, condoms for contraception.

ROS: Only positive findings are seen in HPI

Physical Exam:

VS: Pulse – 104; BP – 108/60 RR – 14; T – 98.8F (37 C); SpO2 – 98%

Gynecologic: Tenderness noted to bimanual exam. Left Adnexal fullness seen without mass. Uterus is
enlarged and softened.

ASSESSMENT/PLAN

Test Results:
• Human chorionic gonadotropin (hCG), plasma: Value consistent with 5-6 w normal

, gestation, suggest transvaginal ultrasound.
• TVUS: high probability of left fallopian tube ectopic pregnancy
• LFTs: Normal (allows her to be Methotrexate candidate)
Management Plan

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