Pamela Flowers – OBGYN

Diagnosis – Ectopic pregnancy

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 )

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)

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