Nancy Penn – OBGYN
CC – Pelvic pain
Is it possible you’re pregnant/ breast tender/ bleeding between cycles
Pretest- actions for acute abdominal
... [Show More] pain
Asses for signs of shock / hemodynamic instability
Pregnancy test (for all women of childbearing age)
Order blood products immediately in unstable patients with suspected active hemorrhage
Obtain/Preform bedside imaging in unstable patients with suspected pneumoperitoneum or
hemoperitoneum.
Administer Antibiotics early in the setting of sepsis, peritonitis, or perforated viscous
Provide adequate analgesia
Obtain immediate surgical consultation in the setting of an acute abdomen with hemodynamic
instability.
Diagnosis – Ectopic pregnancy
Tests- hcg urine, ua, pelvic ultrasound, cbc
Problem Statement:
( Demographic description – chief complaint – Hx and PE key findings – risk factors )
Nancy Penn is a 22 year old female G0P0 presenting with severe stabbing 9/10 diffuse pelvic pain that
started 1 hour ago. She is tachycardic (R=120) and hypotensive (89/50 mmHg) and nauseated.
Genitourinary exam shows cervical motion tenderness and tenderness to uterine palpation without
masses. She is sexually active with her boyfriend and uses condoms inconsistently. She has a history of
PID 1 year ago treated successfully and reports her period was 2 months ago and is 1 month late.
CC: Nancy Penn is a 22 year old female G0P0 presenting with severe stabbing 9/10 diffuse pelvic pain
that started 1 hour ago.
HPI: She reported the pain came on suddenly and sharply. She also reports with the pain – nausea and
lightheadedness upon standing. Patient reports her last period was 2 months ago.
Meds: none.
PMH: Patient occasionally smokes, and has a history for pelvic inflammatory disease 1 year ago.
SH: Patient is sexually active with her boyfriend and inconsistenly use condoms
ROS: Only positive findings are seen in HPI
Physical Exam:
VS: Pulse – 120 tachycardic; BP – 89/50 hypotensive RR – 20; T – 99F (37 C); SpO2 – 97%
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Abdominal: no signs of trauma
Gynecological: Moderate cervical-motion tenderness, moderate tenderness to direct uterine palpation
without masses in adnexa.
ASSESSMENT/PLAN
Test Results:
HCG (urine): positive
HCG (blood): positive – for 6week pregnancy
CBC: WBC elevated (nonspecific inflammation), hemoglobin and HCT low reflecting acute blood
loss
UA: Normal
Pelvic Ultrasound: ultrasound shows empty uterus w/ hyperechoic matter surrounding, as well
as Right adnexal ectopic pregnancy w/ free fluid and clotted blood.
LFT: to assess ability to use Methotrexate.
FAST (Focused Assessment with Sonography in Trauma) Scan: Positive for free fluid in
hepatorenal recess and perisplenic space
CT abdomen with IV contrast: positive for abdominal/pelvic free fluid consistent with blood.
Blood type / crossmatch: Type 0, Rh positive
Management Plan
Methotrexate
Monitor b-hCG levels after 1 week of MTX.
If no improvement consider salpingostomy / salpingectomy [Show Less]