Patient

A CASE OF A 40 YEAR-OLD G7P6(5-1-0-5), married, Roman Catholic, was referred for further evaluation and management.
Condition started 2 days PTA when she noted vaginal spotting. This was accompanied by tolerable hypogastric pain. Noting that she was already 2 months pregnant, she went to the health center for consult. She was then referred to Hospital where she was managed as a case of Threatened Abortion. No relief was noted inspite of unrecalled oral medications that were given. She was requested for transvaginal ultrasound, however, this was not carried out since there was no Sonologist available at that time.
6 hrs PTA, the patient had profuse vaginal bleeding and blood pressure dropped to 90/50mmHg from a baseline of 150/90 mmHg. There was also note of   passage of grape-like tissues per vagina. A double IV line was secured, and hydration was done. 1 dose of IV Tranexamic Acid was also given.  When the BP stabilized at 100/60 mmHg, the patient was transferred to our center for further evaluation and management.
The patient is not a known hypertensive, diabetic, nor does she have any chronic illnesses. She has no known allergy to foods and drugs.
Family history is unremarkable.
Menarche was at 11 years old with subsequent menses occurring at regular monthly intervals, lasting for 4-5 days, soaking 2-3 regular pads on heavy days, occasionally with menstrual periods accompanied by dysmenorrhea.
She is G7P6 with the last delivery in 2019 to a full term baby boy in Hospital. Her 1st up to the 4th pregnancy were delivered at home assisted by a midwife. Her 5th pregnancy was preterm at 35 weeks and delivered at Hospital. Her LMP was in June 25, 2021. She did not have any check up yet for this pregnancy, although she did home pregnancy test which was positive,  nor was there any intake of vitamins. She was apparently well until she had vaginal spotting.
She is an elementary graduate but remains a housewife to take care of her children. Her husband is a carpenter being employed by a local contractor.
She was received stretcher-borne, conscious, and not in cardio-respiratory distress.
Vital signs were the following: BP= 100/60mmHg, Pulse Rate= 112 bpm, RR=21 cpm, T= 36.9 centigrade
Pallor was noted. Chest and lungs had clear breath sounds. Tachycardia was noted, but  without any murmur with regular rhythm. Abdomen was full with the uterus palpated around 2 cms from the symphysis pubis. No FHB was noted.
Pelvic Exam: External Genitalia= grossly normal , Intoritous = parous with scanty blood flowing out of the vagina. Speculum Exam= blood clots were noted at the vaginal vault, cervix was bluish, slightly enlarged, with placenta-like tissues occupying the cervical os. I/E (bimanual exam) = cervix was soft, 3 cms open with tissues palpable at the cervical os. Uterus measured 14 cms, non-tender.  Adnexae were non tender with a 4X5 cms movable cystic mass palpated on the right. There were vesicular tissues (grape-like)  noted upon removal of the examining finger.

The patient was admitted.

I. PRIMARY CLINICAL IMPRESSION:
a. What is your primary clinical impression?
b. What are your bases for your impression? (From history and pe)
c. Give at least five differential diagnosis (Rule In, Rule Out) from history and pe
II. DIAGNOSTIC APPROACH
a. What diagnostic tests will you request starting from the ER and state indications.
III. What is your complete diagnosis?
IV. Pathophysiology in diagram (with explanation)
V. Management
VI. PROGNOSIS/ANTICIPATED COMPLICATION