History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Differential Diagnosis
Relevant Testing
Test Results
Case Event
Diagnosis
Treatment Orders
Question 1
Question 2
About the Case
Vaginal bleeding in a pregnant 32-year-old woman
Physical Examination
General appearance
: Appears well and in no distress.
Vital signs
:
Temperature: 37° C
Pulse: 88 beats/min
BP: 118/64 mm Hg
Respirations: 20/min
Skin
: No petechiae, ecchymoses, or other lesions.
HEENT
: No scleral icterus or signs of bleeding.
Pulmonary
: Lungs clear
Cardiovascular
: Mild tachycardia; regular rhythm, no murmurs, rubs, or gallops.
Gastrointestinal
: Gravid abdomen, fundal height normal for dates. Uterus normal tone, nontender.
Genitourinary
: Scant dried brown blood at the introitus. On speculum exam, a few milliliters of dark red blood are present in the vaginal vault. The cervix appears approximately 1-cm dilated, no active bleeding. Bimanual examination not done.
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