Case Analysis Tool Worksheet
Student’s Name:
I. Epidemiology/Patient Profile
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16-year-old Savannah, who is pregnant, returns to the clinic with vaginal bleeding. Her mother Leslie is also with her. Savannah seems to know her history. |
II. Prioritized Cues from Hx and PE.(Do not include lab, x-â€ray, or other diagnostic test results here.)
• Tier 1: The cues (may be positive or negative) that contribute most to the diagnosis of the active problem.
• Tier 2: These are cues of intermediate importance (list only positive cues).
• Tier 3: Of least importance (list only positive cues).
Tier 1 Tier 2 Tier 3
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Second episode of vaginal bleeding |
Denies of dizziness and lightheadedness |
Physically active and plays softball |
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She described the bleeding as on and off with clots for one hour. |
Had sexual intercourse during pregnancy |
Healthy diet |
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Abdominal cramping |
V/S: Temp 98.4, BP 105/75, PR 90 |
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Pooled blood in the vaginal wall |
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2 cm cervical os |
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Uterus is non-tender |
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None palpable adnexal mass |
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Abdomen is soft and nontender |
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Absent fetal heart tone |
III. Problem Statement
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Savannah, a 16-year-old pregnant woman who is 8 weeks AOG by LMP and whose pregnancy was confirmed intrauterinally with fetal heart tones by ultrasound 10 days earlier, returns to the clinic complaining of vaginal bleeding that has been intermittently occurring over the past hour and containing clots. Pooled blood was found during the pelvic exam, along with a 2 cm open cervical, no cervical motion pain, and no adnexal tenderness. During this visit, an ultrasound showed no fetal activity or heartbeat. |
IV. Differential Diagnosis
Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient’s complaint(s).
List your most likely diagnosis first, followed by two other reasonable possibilities. For some cases, fewer than 3 diagnoses will be appropriate.
Then, enter the positive or negative findings from the history and the physical examination that su
Aquifer Essay Title
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Aquifer Essay Title
The introduction should be a paragraph that provides a brief overview of the case and main diagnosis with rationale and supporting evidence. You do not need to discuss pathophysiology or summarize the entire case. The entire paper should be between one and three pages long.
Differential Diagnoses
This section will identify your two differentials with the rationale and supporting evidence. Also explain why these differentials were not the main diagnosis.
Diagnostics
Identify the lab, radiology, or other tests needed for the main diagnosis with supporting evidence. Do not include excessive or non-pertinent testing.
Treatment, Education, and Follow-Up
This section should include the elements of an initial treatment plan for the main diagnosis. It should include medication names, dosages, frequencies; patient/family education; appropriate follow up plan; and hospitalizations and consults when appropriate.
References
The supporting evidence for this paper should be derived from at least two primary sources (not Medscape, UpToDate, Epocrates, etc.), including published clinical guidelines or peer-reviewed professional journals that are NOT textbooks. Supporting evidence should be published within the past 5 years, or 10 if the guidelines have not been updated. References should be in APA format. Refer to the APA 7 Manual for specific formatting requirements.
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