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Vaginal Bleeding

A 24-year-old woman with a history of depression presents with vaginal bleeding and lower abdominal pain. Her last menstrual period (LMP) was 3 weeks ago. Vital signs include blood pressure (BP) 96/60 mm Hg, heart rate (HR) 110 beats/minute, and temperature 98.6°C. Exam shows lower abdominal tenderness in the left lower quadrant.

What is the most important laboratory test in determining your differential diagnosis?

a. Complete blood count (CBC)

b. Blood type

c. Urine pregnancy test

d. Creatinine level

e. Thyroid-stimulating hormone (TSH)

The answer is c. A urine or serum β-hCG should be one of the first ancillary tests ordered in any female of reproductive age, especially in those presenting with vaginal bleeding or abdominal pain regardless of their sexual, contraceptive, and menstrual history. Recent period does not rule out pregnancy; up to 15% of patients with ectopic pregnancy report no missed menses. Urine tests are rapid and reliable, but follow-up serum quantitative β-hCG may be warranted if the urine test is positive. A patient with vaginal bleeding or abdominal pain who has a positive pregnancy test needs to have the status of her pregnancy determined and ectopic pregnancy excluded. Diagnosis of pregnancy may also distinguish between an emergent cause of vaginal bleeding (eg, ectopic pregnancy) versus a nonemergent cause (eg, pathologic cervical lesion).

A CBC (a) may be helpful in distinguishing such conditions as immune thrombocytopenia and to evaluate for anemia. Although a blood type (b) may be necessary in a patient with severe vaginal bleeding and hemodynamic instability, this patient is currently stable. A blood type is also indicated if the patient is found to be pregnant in order to determine her Rh status. Creatinine (d) evaluates for kidney function and although this number is helpful, it does not drive the evaluation in this clinical case. Similarly, abnormal TSH levels (e) may indicate a cause for abnormal uterine bleeding, but does not cause focal abdominal pain. Remember the most important initial step in evaluating a woman of reproductive age presenting with abdominal pain or vaginal bleeding is to determine pregnancy status.

A 24-year-old woman with a history of depression presents with vaginal bleeding and lower abdominal pain. Her last menstrual period (LMP) was 3 weeks ago. Vital signs include blood pressure (BP) 96/60 mm Hg, heart rate (HR) 110 beats/minute, and temperature 98.6°C. Exam shows lower abdominal tenderness in the left lower quadrant.

The patient’s HR improves with 1-L intravenous (IV) crystalloid and her pain improves with 50 μg fentanyl intravenously. She has a positive urine pregnancy test and quantitative β-human ...

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