Level 3: Vaginal Bleeding – Contrasting Case #1: Patient Information

Given these changes from the original case, what is your diagnosis?

What is your diagnostic explanation?

As compared to the long case, this patient is a 15 year old female who presents with the complaint of heavy vaginal bleeding.

HPI: Patient states that over the past few days she has noticed that she has been having bloody vaginal discharge. She has never had anything like this before. She has also been having lower abdominal pain the past few days. In the past few months she has begun to gain weight and have acne breakouts on her face.

PMH: No known drug allergies. No current medications.

SH: Non-smoker. Single.

FMH: Mother has hypertension and diabetes. Father has hypertension and coronary artery disease.

ROS: As per HPI

PE: Mildly pale young woman who appears her stated age.
VS – Height 5’5” Weight 150lb BMI 25 HR82 BP110/75 RR16 98.5F
Cardiac – S1 and S2 audible. Regular rate and rhythm. No murmurs
Lungs – Clear to auscultation bilaterally. No adventitious sounds present.
Abdomen – Soft, nondistended. Mild lower abdominal tenderness. No organomegaly present.
GU – Normal appearing labia majora and minora. Dried blood in vaginal vault.

CBC reveals moderate anemia.