History of Present Illness:

25 y/o F, G3P2002 with no PMHx, who presents to the ED c/o vaginal bleeding x 1 day. The patient states her LMP was 2/11/2021. She reports taking three pregnancy tests at home, all of which were faintly positive. Patient states she noticed some brown colored bleeding after wiping yesterday but denies soaking pads. She states she had another episode this morning, which prompted her to come to the ED. She also reports intermittent left lower abdominal pain but denies fever, chills, weakness, chest pain, shortness of breath, headache, dizziness, nausea, vomiting, vaginal discharge, vaginal pain or other symptoms at this time. Patient denies seeing an OBGYN yet for this pregnancy.

PMHx: denies

PSHx: C-section 2013 with no complications

Family History: non-contributory

Medications: none

Allergies: NKDA

Social history: Denies tobacco, alcohol or drug use. Married to husband and in a monogamous relationship.

Review of Systems:

Gen: Denies fever, chills, fatigue or weakness

Resp: Denies cough, shortness of breath, wheezing, sputum production.

CV: Denies chest pain, palpitations, leg edema

GI: Admits left lower abdominal pain. Denies nausea, vomiting, hematemesis, diarrhea or constipation.

GU: Admits to vaginal bleeding. Denies dysuria, hesitancy, flank pain, frequency, hematuria or urgency.

MSK: Denies muscle or joint pain, redness or stiffness.

Skin: Denies rash or changes to skin.

Neuro: Denies weakness, dizziness, lightheadedness, headaches.

Psych: Denies confusion

Physical Exam:

VS: T 98.5 F, BP 103/62, HR 88 bpm, RR 18, O2 sat 100%, Ht 5’4”, Wt 130 lb, BMI 22.31

Gen: Alert and oriented, in no acute distress. Sitting comfortably on stretcher. Not ill or toxic appearing. Anxious appearing.

HEENT: Normocephalic, atraumatic

Eyes: PERRL

CV: Regular rate and rhythm, no murmurs.

Resp: No respiratory distress. Clear to auscultation bilaterally

Abd: Soft, nondistended, nontender. Normoactive bowel sounds.

GU: Tanner stage 5. No lesions or tenderness to external genitalia. Scant bleeding in vaginal vault. No adnexal tenderness or CMT. Cervical os closed.

Differentials: ectopic pregnancy, threatened abortion, TOA, ovarian torsion

Assessment:

25 y/o F, G3P2002, with vaginal bleeding x 1 day and LMP 2/11/2021. Patient is in no acute distress, vital signs stable and scant vaginal bleeding on pelvic exam. Urine pregnancy in ED is positive.

Plan:

HCG Quant

CBC

BMP

T&S

UA and culture

Transvaginal US

Addendum:

WBC 6.63, RBC 5.04, HGB 13.5, HCT 40.7, PLT 146

BMP WNL except creatinine 0.4 and glucose 125

UA with small amount of blood, trace leukocyte esterase and moderate bacteria

HCG-Quant 31 mlU/mL

TVUS: Thickened endometrium cavity most likely physiological, clinical correlation. No intrauterine pregnancy. No fetal pole or fetal heart activity demonstrated, please continue monitoring with beta-hCG.

Disposition:

Patient consulted with OBGYN.

Patient with threatened abortion. Will be discharged home and follow up in 48 hours for repeat BhCG and US. Patient will be treated with Macrobid for asymptomatic bacteriuria.

Patient education:

After reviewing your history, labs and ultrasound, you have a threatened (abortion) miscarriage. There was no sign of fetal heart activity or an intrauterine pregnancy on your ultrasound. This may be due to the miscarriage or because it is too early in the pregnancy to see the fetus. Please come back to the ED in 48 hours for a repeat pregnancy blood (hCG) test to measure the level of the pregnancy hormone and for another ultrasound. Additionally, you will be sent home with an antibiotic called Macrobid because of bacteria in your urine. Please return to the ED sooner for any new or worsening symptoms.