OB-GYN Case Studies

HISTORY AND PHYSICAL EXAMINATION

DIAGNOSIS

Incomplete abortion.

SUMMARY

This patient is a 16-year-old gravida 1, para 0, menarche at age 13, whose last menstrual period was March 11, who had a positive beta hCG; previous to that, normal menstrual cycles every
28 days.  She says that she has never had a Pap smear.  She was originally seen 2 days ago regarding vaginal bleeding and thought that she had passed some tissue.  She felt that she probably had spontaneously aborted completely.  She was told to come to the office in the event of any increased vaginal bleeding.  The bleeding temporized yesterday, but it then became heavy today with a lot of uterine cramps and passing of large clots and some further tissue-like material per vagina.  She did not save any of this material for us for examination.

At the time of the office visit today, she was bleeding more than would be usual for her period, with crampy abdominal pain, and the cervical os was open and blood clots were seen protruding from the os.

PHYSICAL EXAMINATION

GENERAL:  She is alert and oriented x3, in no acute distress.

VITAL SIGNS:  Blood pressure 100/66, respirations 16, pulse 76, temperature 98.6.

PELVIC:  Pelvic examination reveals essentially healthy vagina with blood in the vault and cervical os.  The uterus is anteverted, 6 weeks’ size, and mobile.  Adnexa are grossly normal.  No palpable masses.

RECTAL:  Rectal examination was negative.

I sent her for a sonogram to confirm an incomplete abortion, which was confirmed.

PLAN

We will proceed with suction curettage under general anesthesia.  She has been n.p.o since 1 o'clock, and preoperative blood work has been sent, including CBC, PT, PTT, and urinalysis.  She will be done under outpatient surgery.

FOOTNOTE

Line 13 (Page 1).  Alternative:  HCG (human chorionic gonadotropin).

Line 39 (Page 1).  For clarity the abbreviation AB was expanded to abortion.