Level 3: Vaginal Bleeding – Contrasting Case #3: 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 she has noticed that she has been having bloody vaginal discharge since last night. She has never had anything like this before. She has some pain/aching in the vaginal vault. She seems shy and nervous, and is reluctant to give much information.

PMH: No known drug allergies. No current medications.

SH: Non-smoker. Single. Lives at home with mother and stepfather.

FMH: Mother has hypertension and diabetes. Father is unknown.

General – No fatigue, fever, chills
Cardiovascular – No chest pain or palpitations
Respiratory – No cough, shortness of breath.
GI – No nausea/vomiting. No diarrhea/constipation.
GU – No dysuria, hematuria, urinary frequency. Bloody vaginal discharge.
Musculoskeletal – No muscle aches/pains, no joint swelling

PE: Patient appears a bit pale, but otherwise in good health. She is tearful and withdrawn
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. No organomegaly present.
GU – Labia majora and minora are slightly erythematous. Bruising present on inner thighs. Ecchymosis with hymenal transection at the 7 o’clock position with slight bleeding when touched with Q-tip.