Case Study For Patient With Irregular Vaginal Bleeding

Case Study For Patient With Irregular Vaginal Bleeding

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Vaginal Bleeding, Adult Female

The presented case study features a 28-year-old woman who presents to her primary care physician complaining of dizziness, fatigue, headache, and abdominal cramping for a period of 3 days with irregular vaginal bleeding. She expresses concern over her symptoms as she had missed her last period and confirmed pregnancy through a home test. She notes that her bleeding pattern is consistent with her previous pregnancies. Notable medical history includes a cholecystectomy and chlamydia infection. She seemed anxious and a little fatigued during the physical assessment, with complaints of moderate abdominal pain on palpation. She is a mother of two, with a desire for another child, and has no known drug or food allergies. Case Study For Patient With Irregular Vaginal Bleeding

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Differential Diagnoses and Most Likely Diagnosis

Based on the patient’s symptoms and history, the differential diagnosis could be early pregnancy complications such as ectopic pregnancy, threatened abortion, or molar pregnancy, among other non-pregnancy-related conditions like pelvic inflammatory disease or hormonal dysregulation. The most plausible diagnosis would be a threatened abortion since she just had her pregnancy test come out positive, and developed vaginal bleeding and abdominal pain which are major risk factors for miscarriage though she has no fever or features suggestive of an infection. The patient’s history of similar bleeding in previous pregnancies also favors this possibility.

Pathophysiology

Threatened abortion, or threatened miscarriage, involves vaginal bleeding that occurs in the first 20 weeks of pregnancy without the cervix dilating or passing tissue (Mouri et al., 2024). The pathophysiology includes partial separation of the placenta from the uterine wall, leading to bleeding. The separation can result from various factors, such as hormonal imbalances, physical trauma, or uterine abnormalities. The bleeding and cramping occur due to the body’s inflammatory response and attempt to expel the detached tissue, though the cervix remains closed, distinguishing it from an inevitable miscarriage where the cervix is open. Case Study For Patient With Irregular Vaginal Bleeding

Appropriate Studies, Management, and Risk Factors

Tests and imaging studies should be done to further confirm the diagnosis and rule out other conditions that may be causing similar symptoms. A transvaginal ultrasound is essential in confirming or excluding an ectopic pregnancy and molar pregnancy, in addition to determining the location and viability of the pregnancy. Subsequent beta-hCG (human chorionic gonadotropin) levels should be taken to assess the progress of pregnancy (Mouri & Rupp, 2020). A complete blood count (CBC) will determine the patient’s hemoglobin levels and whether there might be significant blood loss. The management plan that follows entails explaining to the patient the need to avoid lifting heavy items or engaging in any strenuous activity followed by close monitoring of her symptoms. Most ectopic pregnancies occur in the fallopian tubes. Threatened abortion is associated with several risk factors which include increased maternal age, previous history of miscarriage, structural and functional abnormalities in the uterus, and continued smoking and alcohol intake during pregnancy (Zhao et al., 2024)Case Study For Patient With Irregular Vaginal Bleeding. Management tends to be conservative including complete bed rest and, if needed, administration of progesterone supplements. If a viable intrauterine pregnancy is seen on ultrasound the patient should be re-assured and kept under follow-up. In case of ectopic pregnancy or an inevitable miscarriage, then surgical or medical management would be required.

ICD-10 and CPT Codes, Patient Education, Medical/Legal Concerns, and Interprofessional Collaboration

The pertinent ICD-10 code for this visit is O20.0 for threatened abortion, given the patient’s symptoms of vaginal bleeding and abdominal cramping during early pregnancy. The CPT (E/M) code would be 99214 for an established patient office visit with a moderate level of complexity, considering the detailed history, examination, and medical decision-making involved. Patient education should include information about the importance of rest, avoiding strenuous activities, and monitoring for increased bleeding or pain. She should be instructed to seek immediate medical attention if symptoms worsen. If not managed appropriately, the medical/legal concerns may include failure to diagnose an ectopic pregnancy or miscarriage, which could lead to severe complications such as uterine rupture, inevitable abortion, and hypovolemic shock, which can result in potential litigation (Mouri & Rupp, 2020). Interprofessional collaboration is essential in this case, involving an obstetrician-gynecologist (OB/GYN) for specialized care and monitoring of the pregnancy, a radiologist for interpreting the ultrasound, a primary care physician for ongoing health management, and a mental health professional for providing support and counseling to address anxiety and emotional stress related to the pregnancy complications Case Study For Patient With Irregular Vaginal Bleeding.

Conclusion

The patient presented in the case most likely experiencing a threatened abortion. Prompt diagnostic testing, including a transvaginal ultrasound and serial beta-hCG levels, is essential to confirm the diagnosis and rule out other conditions like ectopic pregnancy. Appropriate management includes patient education on activity restriction and close symptom monitoring. Interprofessional collaboration with an OB/GYN, radiologist, and primary care physician is crucial for comprehensive care. Addressing her physical and emotional needs will help optimize outcomes for both the patient and her pregnancy

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References

Mouri, Mi., Hall, H., & Rupp, T. J. (2024). Threatened miscarriage. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430747/#:~:text=A%20threatened%20miscarriage%20also%20called

Mouri, Mi., & Rupp, T. J. (2020). Threatened abortion. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430747/

Zhao, Y., Rohan D’Souza, Gao, Y., Hao, Q., Kallas‐Silva, L., Steen, J. P., & Guyatt, G. (2024). Progestogens in women with threatened miscarriage or recurrent miscarriage: A meta‐analysis. Acta Obstetricia et Gynecologica Scandinavica. https://doi.org/10.1111/aogs.14829 Case Study For Patient With Irregular Vaginal Bleeding

 VAGINAL BLEEDING, ADULT FEMALE

Chief Complaint

“Vaginal bleeding.”

History of Present Illness

A 28-year-old woman presents to her PCP with a 3-day history of dizziness, fatigue, and headache. She is the mother of two girls, ages 5 and 2. She and her husband want another child, hopefully a boy, and have planned accordingly. She missed her last period and suspects she is pregnant; a home pregnancy test last week was positive. Until 3 days ago, she felt fine, other than some fatigue and mild nausea. Over the last 2 days, she began experiencing abdominal cramping and irregular vaginal bleeding. She points to both lower and upper quadrants as the main location of the pain. She describes her abdominal pain as 7 of 10. She has not used over-the-counter pain medication because she wants to avoid medication if pregnant. Additionally, she states, “When changing positions, I get lightheaded.” When the PCP asks about her bleeding, she states she has had similar bleeding during her other pregnancies. “All my pregnancies are like that, it’s normal.” Case Study For Patient With Irregular Vaginal Bleeding

Review of Systems

A ROS is positive for fatigue, nausea, abdominal pain, and vaginal bleeding. The patient reports headache and dizziness. The ROS is negative for fever, chills, vomiting, diarrhea, constipation, shortness of breath, or chest pain.

Relevant History

The patient’s medical history is significant for cholecystectomy (age 27) and chlamydia infection (age 17). Her social history includes drinking one glass of wine per weekend since age 18. She had a few male sex partners prior to her marriage. She lives with her husband and children and describes her marriage as happy. Both children were full-term babies and the pregnancies were normal. Her family history is unknown as she was adopted.

Allergies

No known drug allergies; no known food allergies.

Medications

None.

Physical Examination

Vitals: T 37°C (98.6°F), P 70, R 19, BP 130/80, WT 78.7 kg (173.5 lbs), HT 167.6 cm (66 in.), BMI 28.

General: Appears anxious and fatigued, mild acute distress.

Skin, Hair, and Nails: No rash, skin warm and dry. No abnormal findings with hair or nails.

Lungs: Clear to auscultation bilaterally, good air movement throughout.

Heart: RRR, without murmur or gallop.

Abdomen: Abdomen was soft, non-distended, and moderately tender; generalized.

Neurologic: A&O×3, cranial nerves II to XII grossly intact.

Clinical Discussion Questions
What is the differential diagnosis?
What is the most likely diagnosis? Why?
Demonstrate your understanding about the pathophysiology in regard to the most likely diagnosis.
Should tests/imaging studies be ordered? Which ones? Why? Think about tests/imaging beyond the primary care setting as well. Case Study For Patient With Irregular Vaginal Bleeding
What are the next appropriate steps in management?
Demonstrate your understanding about the most common location of the diagnosis, risk factors, and treatment options. Provide reference for your responses.
What are the pertinent ICD-10 and CPT (E/M) codes for this visit? Provide a short rationale.

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What is the appropriate patient education for this case?
If not managed appropriately, what is/are the medical/legal concern(s) that may arise?
Think about interprofessional collaboration for this case. Provide a list of specialties or other disciplines and indicate what contribution these professionals might make to managing the patient Case Study For Patient With Irregular Vaginal Bleeding