History of Present Illness
Kristi Wheeler is a 17-year-old female (G1P0) presenting to the ED with her mother, Lynette, for a scheduled medication abortion. They initially had an appointment with Dr. Abbot at 06:30 but overslept and arrived hours later. The patient's last menstrual period (LMP) was approximately the 23rd of June. She denies any known drug allergies and has no prior surgical history.
Emergency Department Course
Triage Check-In
Patient arrival for a missed procedure appointment.
Triage Check-In
Patient arrival for a missed procedure appointment.
Medical Decision Making
Patient arrived late for a scheduled medication abortion with Dr. Abbot, who has since gone off shift. Triage must check the patient in, verify identity, and route the chart to the next available attending physician capable of completing the evaluation and procedure.
Diagnostics & Findings
Findings:
- Patient is clinically stable, in no acute distress.
Interventions
- Placed in queue for the next available attending physician.
⮑ Outcome & Reassessment
Patient and mother wait in the lobby until called back.
Initial Provider Assessment & Pre-Procedure Evaluation
Provider handoff / Patient evaluation prior to administering abortifacients.
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Initial Provider Assessment & Pre-Procedure Evaluation
Provider handoff / Patient evaluation prior to administering abortifacients.
Medical Decision Making
Dr. Collins is taking over care from the off-going physician. Before administering a medication abortion (typically mifepristone followed by misoprostol), she must establish the patient's medical history, assess gestational age via LMP, and verify there are no medical or surgical contraindications. Most critically, an ultrasound must be ordered to confirm an intrauterine pregnancy, date the gestation to ensure it falls within the safe therapeutic window (typically < 70 days), and rule out an ectopic pregnancy.
Diagnostics & Findings
- Clinical history intake
- Pelvic ultrasound (Ordered/Pending)
Findings:
- First pregnancy (G1P0)
- LMP: June 23 (approximate)
- No drug allergies
- No prior surgical history
Interventions
- Instructed patient to change into a hospital gown for the pending ultrasound examination.
⮑ Outcome & Reassessment
Patient is cooperative, denies any allergies or past medical issues, and prepares for the ultrasound.
Clinical Media
Diagnoses & Disposition
Evolving Diagnoses
- [S01E04]First Trimester Pregnancy (Pending Ultrasound Confirmation)
Current Disposition
In the ED Exam Room, changing into a gown to await a diagnostic pelvic ultrasound.
Casebook Analysis
Episode Context
Kristi and her mother arrive for a medication abortion but missed their original time slot with Dr. Abbot because they overslept and failed to set an alarm. Dr. Heather Collins steps in to assume care, demonstrating standard shift-handoff procedures and continuity of care for a time-sensitive and emotionally delicate procedure.
Attending's Review
Medical Accuracy
The protocol demonstrated by Dr. Collins is highly accurate for a clinical or ED setting handling early pregnancy terminations. Before dispensing mifepristone and misoprostol, it is the standard of care to obtain the Last Menstrual Period (LMP), confirm the patient's allergy profile, check surgical history, and perform an ultrasound. The ultrasound is a critical safety measure to confirm the pregnancy is intrauterine (ruling out life-threatening ectopic pregnancy) and to verify gestational dating, as medical abortions are typically only FDA-approved up to 10 weeks (70 days) of gestation.
Complications & Errors
- Patient non-compliance/delay (missed original 06:30 appointment), which resulted in prolonged wait times and a provider handoff.
Clinical Pearls
Always obtain a baseline pelvic ultrasound prior to prescribing mifepristone and misoprostol to confirm an intrauterine pregnancy and definitively rule out ectopic pregnancy.
Accurate gestational dating via LMP and ultrasound is critical, as the safety and efficacy profiles of medication abortion regimens are gestational-age dependent.
Verify a patient's allergy profile and past medical/surgical history to ensure there are no contraindications to prostaglandins (misoprostol) or anti-progestins (mifepristone).
