Family Nurse Practitioner in the outpatient setting.


Ms. Flowers is a 24-year-old woman who presents to the emergency department with a 24-hour history of acute vaginal bleeding associated with severe, crampy, constant left pelvic pain exacerbated by
movement. She is sexually active, uses condoms inconsistently and uncertain of her last menstrual period. She has none of her usual perimenstrual symptoms; the amount of bleeding is similar to a
heavy period. She is G0P0; history of chlamydial cervicitis 3 years ago; no prior PID or IUD use; ruptured appendix (age 16). Physical exam is significant for tachycardia, LLQ tenderness with
guarding, and absence of rebound tenderness.
DDX: Tubo ovarian abscess vs ovarian cyst vs ovarian torsion vs ectopic pregnancy vs abortion vs PID vs endometriosis vs dysmenorrhea
LABS and TEST: CBC, type and cross, progesterone, UA, HCG, LFT, obstetric ultrasound
Abnormal: highly probable left fallopian tube ectopic pregnancy
A serum progesterone level <5 ng/dl is indicative of non viable pregnancy
Elevated HCG value is consistent with a 5-6 week gestation
Diagnosis : Ectopic pregnancy
Ms. Flowers presents with the classic clinical triad of ectopic pregnancy. Amenorrhea, LLQ pain and abnormal vaginal bleeding.


Discuss the questions that would be important to include when interviewing a patient with this issue. Describe the clinical findings that may be present in a patient with this issue. Are there any
diagnostic studies that should be ordered on this patient? Why? List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each. Discuss your
management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups.


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