Vaginal Bleeding 445410.A 51-year-old woman presents to the ED with heavy vaginal bleeding.
She reports that she has bleeding for 12 consecutive days. She also reports
missing a period 3 months ago, with an ensuing menses that she states was
quite heavy. She denies having any hot flashes, vaginal dryness, night
sweats, or changes in weight. The patient further denies any abdominal or
back pain, syncope, palpitations but states that recently she often feels
lightheaded and can’t perform her normal activities of daily living. Her initial
vital signs include HR of 110 beats per minute, BP of 140/88 mm Hg, RR
of 18 breaths per minute with oxygen saturation of 98% on room air. Upon
physical examination, she appears pale with a nontender abdomen and
warm skin. Her pelvic examination reveals blood clots in the vaginal vault with
a closed os, an enlarged uterus, and no adnexal tenderness. An ultrasound is
performed which does not show any abnormalities. Which of the following
diagnostic tests is most appropriate for this patient?
a. Endometrial biopsy
b. Hormonal therapy trial
c. Laparoscopic examination
d. Dilation and curettage
e. Hysterectomy and salpingectomy
411.A 29-year-old G1P0010 presents to the ED with sharp, right-sided flank
pain of acute onset associated with nausea. The pain began approximately
1 hour before arrival. She denies any fever, hematuria, vomiting, change in
bowel habit, or sick contacts. She cannot recall her last menstrual period at
this time. The patient is afebrile and her vitals are within normal limits as
you begin your physical examination, which reveals a soft abdomen with mild
diffuse tenderness to palpation without rebound. The patient has exquisite
right flank pain. An initial urine dip is negative. Given the information you
have so far, which of the following is the most probable diagnosis?
a. Appendicitis
b. PID
c. Ectopic pregnancy
d. Ureteral stone
e. Diverticulitis