408.A 28-year-old woman presents to the ED with heavy menstrual flow
for the last 2 days with clots. She reports using about two pads every hour.
The patient states that she has occasional metromenorrhagia in the past and
has been treated with oral contraceptives. She reports symptoms of feeling
lightheaded but denies any syncope, palpitations, chest pain, abdominal pain,
or weakness. Her initial vital signs include HR of 96 beats per minute, BP of
135/70 mm Hg, RR of 14 breaths per minute with oxygensaturation of 99%
on room air. Upon physical examination, the patient is obese and you note
a pronounced hairline. Which of the following conditions is most consistent
with this patient’s presentation?
a. Intrauterine pregnancy
b. Polycystic ovaries
c. Ectopic pregnancy
d. Follicular cyst rupture
e. Corpus luteum cyst rupture
409.A 22-year-old woman presents to the ED with diffuse pelvic pain and
vaginal bleeding. She reports that it is about the same time that she normally
has her menses. She also reports some pain with defecation, dyspareunia,
and points of dysmenorrhea in the past. The patient states that she has felt
this way before, but that the pain has now worsened and is intolerable. Her
physical examination reveals a soft abdomen with normal bowel sounds
without rebound tenderness. The patient does not guard and there is no
costovertebral tenderness. Her pelvic examination is significant for blood in
the posterior vaginal vault, a closed os and no palpable masses or cervical
motion tenderness. Given this patient’s history and physical examination,
which of the following is the most likely diagnosis?
a. Ureteral colic
b. Pregnancy
c. Ruptured ectopic pregnancy
d. Endometriosis
e. Appendicitis
444 Emergency Medicine