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    Case-Ectopic Pregnancy

    Uploaded by

    Celline Isabelle Reyes

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Case-Ectopic Pregnancy

    Uploaded by

    Celline Isabelle Reyes
    12 views6 pages

    Original Title

    case-ectopic pregnancy

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    12 views6 pages

    Case-Ectopic Pregnancy

    Uploaded by

    Celline Isabelle Reyes

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    istory of Present Problem:

    Jean Simmons is a 22-year-old-


    college student who presents to the
    emergency department with RLQ
    abdominal pain and intermittent
    vaginal bleeding. Her pain started
    suddenly two hours ago and has
    been severe and persistent. She
    noticed a small amount of bright
    red
    vaginal bleeding in the last hour.
    Jean has irregular cycles and it has
    been six weeks since her last
    menses, which is not unusual for
    her.
    She admits to feeling more
    fatigued the last couple weeks with
    intermittent nausea. Jean is 5’ 8”
    and weighs 74 kg (163 lb
    istory of Present Problem:
    Jean Simmons is a 22-year-old-
    college student who presents to the
    emergency department with RLQ
    abdominal pain and intermittent
    vaginal bleeding. Her pain started
    suddenly two hours ago and has
    been severe and persistent. She
    noticed a small amount of bright
    red
    vaginal bleeding in the last hour.
    Jean has irregular cycles and it has
    been six weeks since her last
    menses, which is not unusual for
    her.
    She admits to feeling more
    fatigued the last couple weeks with
    intermittent nausea. Jean is 5’ 8”
    and weighs 74 kg (163 lb
    Jean Simmons is a 22-year-old-
    college student who presents to the
    emergency department with RLQ
    abdominal pain and intermittent
    vaginal bleeding. Her pain started
    suddenly two hours ago and has
    been severe and persistent. She
    noticed a small amount of bright
    red
    vaginal bleeding in the last hour.
    Jean has irregular cycles and it has
    been six weeks since her last
    menses, which is not unusual for
    her.
    She admits to feeling more
    fatigued the last couple weeks with
    intermittent nausea. Jean is 5’ 8”
    and weighs 74 kg (163 lbs.).
    HISTORY OF PRESENT PROBLEM:

    Jean Simmons is a 22-year-old-college student who presents to the emergency department with RLQ
    abdominal pain and intermittent vaginal bleeding. Her pain started suddenly two hours ago and has
    been severe and persistent. She noticed a small amount of bright red vaginal bleeding in the last hour.
    Jean has irregular cycles and it has been six weeks since her last menses, which is not unusual for her.
    She admits to feeling more fatigued the last couple weeks with intermittent nausea. Jean is 5’ 8” and
    weighs 74 kg (163 lbs.).

    Personal/Social History:

    Jean has been sexually active since the age of 16 and has had three male partners in the last six months.
    She insists that they use condoms which she provides. She has a history of an ovarian cyst and was
    treated for pelvic inflammatory disease (PID) six months ago.

    Current VS: P-Q-R-S-T Pain Assessment (5th VS):


    T: 98.4 F
    Provoking/Palliative Movement of any kind/Lying
    still in fetal position

    (36.9 C)
    oral
    T: 98.4 F (36.9 C) oral
    P: 98 (regular) Quality: Sharp/stabbing

    R: 20 (regular) Region/Radiation: RLQ abdomen


    BP: 102/52 Severity: 9/10
    O2 sat: 98% room air Timing: Constant

    CURRENT ASSESSMENT:

    General Apperance Appears uncomfortable, body tense


    RESP. Breath sounds clear with equal aeration
    bilaterally, nonlabored respiratory effor
    CARDIAC: Pink, warm and dry, no edema, heart sounds
    regular with no abnormal beats,
    pulses strong, equal with palpation at
    radial/pedal/post-tibial landmar

    NEURO: Alert and oriented to person, place, time, and


    situation (x4)
    GI: Abdomen soft/tender to gentle palpation in RLQ,
    bowel sounds audible per
    auscultation in all four quadrants

    GU/REPRODUCTIVE: Voiding without difficulty, urine clear/yellow,


    small amount of red vaginal
    bleeding present on maxi pad. Pad is NOT soaked

    SKIN: Skin integrity intact

    Lab Results:

    Complete Blood Count Current: High/Low/WNL? Previous


    (CBC:)
    WBC (4.5–11.0 mm 3) 8.8 WNL 9.5
    Hgb (12–16 g/dL) 9.9 Low 12.8
    Platelets (150-450 155 WNL 225
    x103/µl)
    Neutrophil % (42–72) 70 WNL 68

    Other Labs Current: High/Low/WNL?


    Urine pregnancy Positive pregnancy test High
    Serum HCG quantitative 9250 High
    Rh Factor negative WNL

    Radiology Reports: Pelvic Ultrasound

    RELEVANT Clinical Significance:


    Result

    No gestational sac Ectopic pregnancy indicated due to positive


    observed. Cannot pregnancy test, elevated
    exclude ectopic hCG levels, but no gestational sac observed
    pregnancy within the uterus

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