2/18/20 19:14

LMP: reports December 2019

Chief complaint: vaginal bleeding x 1day

ER consult

19 yo G2P0010 @ likely 8 weeks EGA by last LMP, EDA unknown, poor historian, presents with vaginal bleeding starting 10 am this morning. Pt reports that she had gone to her PMD last Thursday or Friday for a yeast infection and was called today and told she was pregnant. She went to urinate and saw blood and was concerned. Pt reports it is not profuse bleeding but fills the tissues she has put (no pads). Pt also reports mild SOB and sharp lower midline abdominal pain for the past 2-3 days and denies radiation, alleviating/aggravating factors, taking any medication for the pain. Pt reports pain was 10/10 earlier but now is minimal. Pt could not comment on whether the pain was consistent or intermittent or whether her periods were regular usually. Denies f/n/v/d/c, chest pain, urinary symptoms, hx of ovarian cysts/ fibroids/ cancer. Pt reports smoking marijuana today.

 

OB History- Reports being pregnant once before in 2018. TOP.

PMH: unspecified psychiatric disorder, previously admitted to QHC psych in 2017 for paranoid behavior/ substance abuse

PSH: none

Medications: none

Allergies: NKDA

Fam hx- Denies family hx breast/ colon/ovarian/endometrial cancer.

Habits- Smokes 1-2 cigarettes a day for an unspecified extended period of time, occasional alcohol use, frequent marijuana use

Sexual hx- Pt reports 8 male partners in the past year with one current partner and uses condoms with only some partners. Denies hormonal contraception use. Reports history of STI but refused to elaborate.

 

 

ROS:

General: denies fever, chills.

Cardiac: denies palpitations, chest pain.

Respiratory: Reports mild SOB.

GI: Denies diarrhea, constipation, change in bowel habits.

Gynecologic: Reports vaginal bleeding and pelvic pain.

Extremities: denies edema, erythema, loss of sensation.

Lymph nodes: denies enlargement.

Psychiatric: Pt reports being admitted supposedly because she took a drug that was laced

 

General: 19 F female, in mild apparent distress, alternating between bouts of laughing and crying. AOx3

Vitals:

100 bpm, 114/76,18 breaths per minute, 98.8 °F 98% room air

 

CV: RRR. S1 and S2 normal. No murmurs/ gallops/rubs.

Lungs: CTA bilaterally

Abdomen: Tenderness to palpation in midline lower abdomen. Rebound tenderness present. Gravid abdomen. size= dates. BS present in all 4 quadrants.

Back: non-tender, no CVAT bilaterally.

Extremities: no color changes, erythema, edema. Non-tender. Extremities equal in size.

Skin: normal

 

Speculum examination as per Dr. Napoleon: Normal external genitalia. Mild bleeding in vaginal vault.

Bimanual exam: cervical os closed. Uterus is 8 week sized and non-tender. No adnexal masses or tenderness.

 

Pertinent Labs: beta-hCG 374.2

CBC: WBC 12.37

Blood type- O+

Rh positive, antibodies negative

 

Ultrasound: Suggested right extraovarian adnexal mass with associated irregular right fallopian tube. Complex pelvic free fluid. Ectopic pregnancy is not excluded.

 

Assessment: 19 F G2P0010 @ about 8 weeks EGA presenting with vaginal bleeding, pelvic pain, and amenorrhea consistent with ectopic pregnancy. BhCG 374.2. US shows right adnexal mass.

 

Problem List

1. Vaginal bleeding and abdominal pain- possible ectopic
2. Unspecified psychiatric disorder
3. Tobacco/marijuana use
4. Mild SOB
5. Lack of consistent contraceptive use

 

Plan:

Admit for ectopic pregnancy to GYN service

CBC, progesterone

B-hCG q 48 hours

GC/ chlamydia testing

Psych consult

Consider MTX treatment

IV fluids

NPO

 

Differentials:

1. Ectopic Pregnancy- Likely because of elevated beta-hCG, vaginal bleeding, adnexal mass on US, and amenorrhea. Risk factors of smoking, history of STIs, and multiple partners.
2. Spontaneous abortion- consistent with bleeding and abdominal pain and at increased risk because of tobacco use. Inconsistent with right adnexal mass on US.
3. Vaginal trauma- could result in vaginal bleeding, lower abdominal pain, and psychiatric symptoms. More likely to be pregnancy-related however because elevated BhCG
4. Uterine fibroids- consistent with lower abdominal pain and vaginal bleeding. Unlikely because bleeding is acute starting this am and bleeding is unrelated to period. Also does not explain low beta-hCG levels.
5. Ovarian cyst- possible because of adnexal mass presence, but unlikely because vaginal bleeding is uncommon and ovarian cysts typically present with unilateral not midline pain. Also, does not explain low beta-hCG levels for gestational age.