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Case Analysis Tool Worksheet

Student’s Name:

I. Epidemiology/Patient Profile

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-‐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

Second episode of vaginal bleeding

Denies of dizziness and lightheadedness

Physically active and plays softball

She described the bleeding as on and off with clots for one hour.

Had sexual intercourse during pregnancy

Healthy diet

Abdominal cramping

V/S: Temp 98.4, BP 105/75, PR 90

Pooled blood in the vaginal wall

2 cm cervical os

Uterus is non-tender

None palpable adnexal mass

Abdomen is soft and nontender

Absent fetal heart tone

III. Problem Statement

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

Your Name

United States University

Course name

Instructor name


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.


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.


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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