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Case Analysis Tool Worksheet

Student's Name:

I. Epidemiology/Patient Profile

16-year-old Savannah, who is pregnant, returns to the clinic with vaginal bleeding. Her mother Leslie is also with her. Savannah seems to know her history.

II. Prioritized Cues from Hx and PE.(Do not include lab, x-‐ray, or other diagnostic test results here.)

• Tier 1: The cues (may be positive or negative) that contribute most to the diagnosis of the active problem.

• Tier 2: These are cues of intermediate importance (list only positive cues).

• Tier 3: Of least importance (list only positive cues).

Tier 1 Tier 2 Tier 3

Second episode of vaginal bleeding	Denies of dizziness and lightheadedness	Physically active and plays softball
She described the bleeding as on and off with clots for one hour.	Had sexual intercourse during pregnancy	Healthy diet
Abdominal cramping	V/S: Temp 98.4, BP 105/75, PR 90
Pooled blood in the vaginal wall
2 cm cervical os
Uterus is non-tender
None palpable adnexal mass
Abdomen is soft and nontender
Absent fetal heart tone

III. Problem Statement

Savannah, a 16-year-old pregnant woman who is 8 weeks AOG by LMP and whose pregnancy was confirmed intrauterinally with fetal heart tones by ultrasound 10 days earlier, returns to the clinic complaining of vaginal bleeding that has been intermittently occurring over the past hour and containing clots. Pooled blood was found during the pelvic exam, along with a 2 cm open cervical, no cervical motion pain, and no adnexal tenderness. During this visit, an ultrasound showed no fetal activity or heartbeat.

IV. Differential Diagnosis

Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient’s complaint(s).

List your most likely diagnosis first, followed by two other reasonable possibilities. For some cases, fewer than 3 diagnoses will be appropriate.

Then, enter the positive or negative findings from the history and the physical examination that support each diagnosis.

Spontaneous Abortion (O03.9)

History Finding(s) Physical Exam Finding(s)

Vaginal bleeding	Pooled blood in the vaginal wall
She described the bleeding as on and off with clots for one hour.	2 cm cervical os
Mild abdominal cramps	Uterus is non-tender
	None palpable adnexal mass
	Abdomen is soft and nontender
	Absent fetal heart tone
	No cervical motion tenderness

(Dugas & Slane, 2019)

Alternative dx:

Threatened abortion (O20.0)

History Finding(s) Physical Exam Finding(s)

Vaginal bleeding	Pooled blood in the vaginal wall
She described the bleeding as on and off with clots for one hour.	Uterus is non-tender
Mild abdominal cramps	Abdomen is soft and nontender
	V/S: Temp 98.4, BP 105/75, PR 90

(Prager et al., 2022)

Alternative dx:

Septic Abortion (O03.37)

History Finding(s) Physical Exam Finding(s)

1st trimester vaginal bleeding	Pooled blood in the vaginal wall
	Intact embryonic remains inside the uterus but without fetal heartbeat

(Dulay, 2020)

V. Explanation of Diagnostic Plan (including tests, labs, imaging studies, etc.) and Treatment Plan in prioritized order:

Diagnostic Plan Rationale

Examination of the pelvis and history	Miscarriages are evaluated based on the type of abortion, which has several diagnostic and therapy options. Unavoidable abortion results from an open cervical os without the passage of fetuses
Beta-HCG levels	Beta-human chorionic gonadotropin (beta-hCG) measurement and pelvic ultrasound are the only ways to reliably diagnose a missed abortion because it lacks any other symptoms or indicators. These tests also assist identify whether an intrauterine pregnancy is likely.
Pelvic ultrasound	If an ectopic pregnancy or an early pregnancy loss is suspected when an intrauterine pregnancy is not visible on ultrasound with a beta-hCG concentration over the discriminatory limit. If the mean gestational sac diameter on pelvic ultrasonography is greater than or equal to 25 mm but contains no embryo, or if the embryo's crown-rump length is greater than or equal to 7 mm, but there is no cardiac activity, spontaneous abortion can be identified.
Complete Blood Count	Investigate the possibility of anemia and infection.
Sexually transmitted disease screening	May need to treat possible STIs
Blood typing and RhD screening	If transfusion is necessary, determine the blood type that may be transfused, the RhD status, and the patients that are RhD negative.

Treatment Plan Rationale

Mifepristone 200 mg taken orally, followed by 800 mcg of misoprostol administered intravaginally, buccally, or sublingually, in a 24-hour period	Women who want to avoid uterine instrumentation but also prefer a more predictable timeline for pregnancy ejection and miscarriage complete might prefer this alternative.
Surgical Management: Dilatation and Curettage or Uterine aspiration.	With expectant or pharmacological therapy, a patient on therapeutic anticoagulation may have a higher bleeding risk; surgical management may be preferred in this situation. Additionally, a person who favors a swift and predictable end to pregnancy loss may select surgical management.
Rhogam 50-120 mcg intramuscularly	Within 72 hours following the start of a miscarriage, women who are Rh (D) negative and have not yet been sensitized to Rh (D) factor should be given Rh (D) immune-globulins.
Tylenol 650 mg table, 1 tablet every 6 hours, quantity 90 refills 2.	As needed for pain and discomfort.
Follow-up in a week	Screening for depression, HCG levels, and a possible repeat ultrasound