Mona Gruner, a 23 year old woman, presents with PV bleeding for 2 days, not heavy but using 3-4 pads in the last 24 hours. Her periods are usually irregular occurring every 4-6 weeks for 4-5 days. Her last period was 8 weeks ago. Examination reveals a slightly enlarged uterus consistent with a 6 week pregnancy. A positive beta HCG confirms pregnancy. Differentials include normal delayed period, normal pregnancy, ectopic pregnancy, or threatened/complete miscarriage. Given the positive pregnancy test and irregular bleeding, Mona requires referral to hospital for possible admission and further investigation and management.
Mona Gruner, a 23 year old woman, presents with PV bleeding for 2 days, not heavy but using 3-4 pads in the last 24 hours. Her periods are usually irregular occurring every 4-6 weeks for 4-5 days. Her last period was 8 weeks ago. Examination reveals a slightly enlarged uterus consistent with a 6 week pregnancy. A positive beta HCG confirms pregnancy. Differentials include normal delayed period, normal pregnancy, ectopic pregnancy, or threatened/complete miscarriage. Given the positive pregnancy test and irregular bleeding, Mona requires referral to hospital for possible admission and further investigation and management.
Mona Gruner, a 23 year old woman, presents with PV bleeding for 2 days, not heavy but using 3-4 pads in the last 24 hours. Her periods are usually irregular occurring every 4-6 weeks for 4-5 days. Her last period was 8 weeks ago. Examination reveals a slightly enlarged uterus consistent with a 6 week pregnancy. A positive beta HCG confirms pregnancy. Differentials include normal delayed period, normal pregnancy, ectopic pregnancy, or threatened/complete miscarriage. Given the positive pregnancy test and irregular bleeding, Mona requires referral to hospital for possible admission and further investigation and management.
Mona Gruner, a 23 year old woman, presents with PV bleeding for 2 days, not heavy but using 3-4 pads in the last 24 hours. Her periods are usually irregular occurring every 4-6 weeks for 4-5 days. Her last period was 8 weeks ago. Examination reveals a slightly enlarged uterus consistent with a 6 week pregnancy. A positive beta HCG confirms pregnancy. Differentials include normal delayed period, normal pregnancy, ectopic pregnancy, or threatened/complete miscarriage. Given the positive pregnancy test and irregular bleeding, Mona requires referral to hospital for possible admission and further investigation and management.
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INFORMATION FOR CANDIDATE
Your next patient in general practice is a 23 year
old Mona Gruner who complains about having PV bleeding for a few days. Your task is to: Take a history Perform an examination Discuss any investigations and your management with the patient
This is a station where you should ask the examiner first if the patient is stable (she is) HOPC:
Mona noticed pv bleeding about 2 days ago, not very heavy, using 3-4 pads in last 24 hours, no clots, mild, dull supra pubic pains. Similar to her periods which have been always irregular between every 4 and 6 weeks for 4-5 days,. No pain. Her last period was 8 weeks ago. She is sexually active, has been in a stable relationship for 3 years, they use condoms as contraception and she does not think she could be pregnant but is not sure. No nausea and vomiting. O+G Hx: menarche at age 13, always irregular periods between 4 and 6 weeks, normal bleeding, no pains. No pregnancies. Has had regular pap smear tests, last one 6 months ago (normal). No previous PID. PHx.: unremarkable, especially no bleeding disorder, no symptoms of PCOS (acne, facial hair etc.). FHx.: unremarkable SHx.: social worker in a steady relationship, non smoker, non drinker, NKA, no medication. Examination: Well looking woman, normal vital signs. Abdominal examination normal, Genital area on inspection normal, pv speculum normal cervix with os closed, slight bleeding. Bimanual examination reveals slight cervical tenderness, the uterus is slightly enlarged consistent with 6 weeks pregnancy, the adnexae appear normal. Investigations (no results available yet): Beta HCG pregnancy test (positive!) FBE Blood group and Rh typing Transvaginal ultrasound Coag profile Diagnosis and differentials: vaginal bleeding after 8 weeks amenorrhoea: 1. ?normal delayed period 2. ? pregnancy, if beta HCG positive Normal pregnancy (?will I lose my baby? - would she like to have a baby?) Ectopic (u/s) Threatened or complete miscarriage 3. PCOS 4. Unlikely PID Management (depending on investigation results: 1. If normal but very delayed period referral to a specialist for regularisation of her periods might be worthwhile 2. If beta HCG positive: Normal pregnancy: if she wants to keep the baby, the pregnancy could develop Ectopic: medical (methotrexate) or laparoscipic surgical treatment Threatened or complete miscarriage (U/S!): reassurance However, in Monas situation she should be referred to hospital for possible admission!
