( Demographic description – chief complaint – Hx and PE key findings – risk factors )
case study
Pamela Flowers is a 24 year old G0P0 woman presenting with abnormal vaginal bleeding and LLQ pelvic
pain for 1 day. She has a history of dysparenuria on her left side. Gynecological exam shows tenderness
and L- adnexal fullness (no mass) w/ enlarged + soft uterus. Patient has history of irregular periods.
( you just need a treatment plan )
CC: Pamela Flowers is a 24 year old G0P0 woman presenting with abnormal vaginal bleeding and LLQ
pelvic pain
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
This study source was downloaded by 100000830772748 from CourseHero.com on 05-09-2022 08:46:25 GMT -05:00
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller PossibleA. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $8.49. You're not tied to anything after your purchase.
