Identifying Data:

Name: Ms. D

Sex: Female

Address: New York, NY

Date of Birth: 9/15/1992, 28 years old

Date & Time: 6/3/2021, 12:30 PM

Location: Metropolitan Hospital, East Harlem, NY

Religion: Christian

Marital Status: Single

Race: African American 

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Mode of Transport: Car

Chief Complaint: “I have a pain in my stomach” x 1 day

History of Present Illness:

Ms. D is a 28 year old African American woman with no significant PMHx presenting to Metropolitan Hospital ED c/o left sided abdominal pain since last night. She states that she was bending down trying to take off her toe nail polish when she suddenly felt a sharp stabbing pain in her left lower abdomen. When she got up, the pain remained and did not improve. She was able to sleep last night, but when she woke up she was still in pain, so she came in. She describes the pain as constant, sharp and non-radiating, aggravated by coughing, sneezing, moving, or taking deep breaths, and alleviating by sitting or laying still. She states that the pain was an 8/10 last night, but has improved slightly and is a 4/10 today. She denies taking any medications for the pain, and states she has never felt this before. She also admits noticing increased white vaginal discharge over the past 2 weeks, which has a “fishy” odor, but denies hematuria, dysuria, or vaginal pain. She denies being pregnant, and her last LMP was 5/19. She is monogamous with a single male partner and uses contraception. Patient denies history of STI, headache, dizziness, SOB, chest pain, N/V/D/C, numbness or tingling.

Past Medical History:

Present medical illnesses – none

Past Illnesses- asthma, resolved

Childhood illnesses – none

Immunizations – Up to date

Screening Tests- none

Blood Transfusions- none

Past Surgical History:none

Medications: none

Allergies:

No known food, drug, or environmental allergies.

Family History:

Mother – 48, has Asthma

Father – 50, alive and Well

Daughter- 5, Alive and Well

Daughter-3, Alive and Well

Maternal Grandmother- 70- has asthma, diabetes, and breast cancer

Maternal Grandfather- deceased at unknown age and reason

Paternal Grandmother- 75- has COPD

Paternal Grandfather- deceased from prostate cancer at age 67

Social History:

Ms. D is a single female, living at home with her daughters. She works as an office secretary.

Habits – Patient drinks one cup of coffee a day. Admits to occasional alcohol drinking, about once or twice a month, and smoking marijuana about twice a day. Denies smoking cigarettes, use of e-cigarettes or illicit substance use.

Travel- Denies any recent travel.

Safety- Admits to wearing seat belt.

Sleep – Admits that she only sleeps for about 4-5 hours per night, as she has trouble falling asleep.

Exercise – States that she does not regularly exercise or engage in physical activity.

Diet- Patients maintains a balanced diet, including fruits and vegetables. She generally has a breakfast bar and coffee for breakfast, sometimes has pizza or pasta for lunch and eats carbs and vegetables for dinner..

Sexual History: Monogamous, has single male partner. Currently sexually active. Admits to using contraception. Denies history of sexually transmitted infections.

Review of Systems:

General – Admits to fatigue. Denies loss of appetite, recent weight loss or gain, fever, or chills.

Skin, hair, nails –Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies dizziness, headaches, vertigo or head trauma, unconsciousness, head fracture or coma.

Eyes –Admits to use of glasses and contacts. Denies visual disturbances, fatigue, lacrimation, photophobia, and pruritus. Last visit with ophthalmologist was 2 years ago.

Ears –Denies tinnitus, ear pain, hearing loss, discharge, or use of hearing aids.

Nose/sinuses –Admits to nasal stuffiness and congestion. Denies discharge, obstruction or epistaxis.

Mouth/throat –Denies sore throat, sore tongue, bleeding gums, mouth ulcers, voice changes. Last dental exam in March- normal. 

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Breast- Denies lumps, nipple discharge, and pain.

Pulmonary system – Admits to cough and sneezing. Denies dyspnea, dyspnea on exertion, shortness of breath, wheezing, orthopnea, paroxysmal nocturnal dyspnea, cyanosis or hemoptysis.

Cardiovascular system –Denies hypertension, chest pain, palpitations, irregular heartbeat, edema of ankles/feet, syncope or known heart murmur.

Gastrointestinal system –Admits to LLQ abdominal pain. Denies changes in appetite, intolerance to foods, abdominal pain, nausea, vomiting, diarrhea, constipation, dysphagia, pyrosis, flatulence, eructation, jaundice, hemorrhoids, rectal bleeding, or blood in stool. 

Genitourinary system – Admits to urinary discharge. Deniesurinary frequency, urgency, polyuria, oliguria, incontinence, dysuria, hesitancy, dribbling, or flank pain. LMP ended 5/19. G2T2002

Musculoskeletal system – Denies muscle/joint pain, arthritis, deformity or swelling, or redness.

Nervous System– Denies seizures, loss of consciousness, ataxia, loss of strength, change in cognition / mental status / memory, or asymmetric weakness.

Peripheral vascular system –  Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.

Hematological system –Denies easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.

Endocrine system –Denies polyuria, polyphagia, polydipsia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric –Admits to occasional depression/sadness over the past year as a result of being in the house due to COVID. Denies anxiety, OCD or ever seeing a mental health professional.

 Physical Exam

General: 28 year old female, alert and oriented to person, place and time. Patient is obese and has good posture, is well dressed, well groomed, and has good hygiene. Patient appears in no apparent distress.

Vital Signs: BP: 122/75, seated                    

R: 18 breaths/min unlabored     

P:85 beats/min, regular       

T: 98.2 degrees F (oral)                      

O2 Sat: 98% on Room air

Height: 63 inches                Weight: 190 pounds            BMI: 33.7- obese

Skin- Warm and dry, smooth, poor turgor, nonicteric, no lesions, masses, scars, tattoos, thicknesses or opacities.

Hair- average quantity and distribution. Smooth, no lice or seborrhea noted.

Nails- Normal color size and shape of the nails. No spooning, clubbing, beau’s lines fissures, paronychia noted. Capillary refill <2 seconds throughout hands and toes.

Head-Atraumatic, normocephalic. Nontender to palpation on the frontal, temporal, occipital, and parietal areas. No deformities or specific faces noted.

Eyes-Symmetrical OU. Eyebrows and eyelashes even distribution, eyelids have no discharge or swelling, lacrimal glands have no excessive tearing, dryness, enlargement or erythema, lacrimal sac not inflamed or swollen. No evidence strabismus, exophthalmos or ptosis. Sclera white, conjunctiva and cornea clear.  Visual fields full OU. PERRLA, EOMs intact with no nystagmus. 

Ears- Symmetrical and normal size. No lesions, masses or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. Tympanic membrane pearly white/intact with cone of light in normal position AU.

Nose-Symmetrical with some clear discharge bilaterally, no masses, lesions, deformities, or trauma. Nares patent bilaterally, nasal mucosa pink & well hydrated. 

Sinuses- Non-tender to palpation and percussion over bilateral frontal and maxillary sinuses. 

Mouth

Lips -Moist; no cyanosis or lesions

Mucosa -Pink, No masses; lesions noted. No leukoplakia.

Palate – Pink, well hydrated. Palate intact with no lesions; masses; scars. 

Teeth -all teeth intact, good dentition, no cavities noted.

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.

Tongue –Pink; moist, well papillated; no masses, lesions or deviation noted.

Oropharynx – Well hydrated, slightly red, with post-nasal drip; exudate; masses; lesions; foreign bodies. Tonsils present with no exudate. Uvula pink, no edema, lesions. 

Thorax & Lungs 

Chest – Symmetrical, no deformities, no evidence of trauma. Respirations are unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1.

Lungs – Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. No adventitious sounds. 

 Heart-Normal rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. Carotid pulses are 2+ bilaterally without bruits.

Abdomen-Tender to palpation along left upper and lower quadrants, CVA tenderness appreciate on the left side. Abdomen flat and symmetric with no striae, scars or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Abdomen soft and non-tender to palpation across all right quadrants, no guarding or rebound noted. No hepatosplenomegaly to palpation.  

Mental Status Exam- patient is alert, attentive, and oriented. Speech and language are clear and fluent with good word comprehension. Appears to be in good mood, has insight and judgment in his medical problems. Memory and cognitive ability intact, gave accurate information upon assessment of history.

Peripheral Nervous System-

Motor/Cerebellar-Full active/passive ROM of all extremities, pain noted upon hip flexion to right side. Symmetric muscle bulk, no tics, tremors or fasciculation. Strength 5/5 throughout.

Sensory-Intact to light touch, sharp/dull, and vibratory sense throughout.  

Reflexes-2+ throughout.

Peripheral Vascular Exam- Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally, equal in circumference, no edema. No palpable cords or varicose veins bilaterally. No cyanosis, clubbing / edema noted bilaterally.

Pelvic Exam-Significant white creamy discharge blocking the cervix. External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation or erythema. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. No inguinal adenopathy.

Labs:

Ordered CBC, BMP, LFT’s, and Lipase, as well as urinalysis and urine B-HCG, and STI panel

Assessment

Ms. D is a 28 year old African American woman with no significant PMHx presenting to Metropolitan Hospital ED c/o left sided abdominal pain since last night. Her PE was significant for left sided abdominal tenderness/ CVA tenderness and creamy white vaginal discharge.

Differential Diagnoses:

1. Muscle Strain- pain is sharp and came on suddenly when she was bending down in a weird position, she has pain when she breathes/ coughs, so when she is using the muscle.
2. Tubo-ovarian abscess- she has sudden onset of lower abdominal pain, more on the left side, as well as vaginal discharge. However, no fever, nausea, vomiting, or vaginal bleeding
3. Functional Ovarian Cyst- she has sudden onset of lower abdominal pain, more on the left side, and it is midway during her cycle
4. Chlamydia- has sharp lower abdominal pain, has creamy white vaginal discharge, and admits to being sexually active
5. Bacterial Vaginosis- has lower abdominal pain and creamy white vaginal discharge with a fishy odor
6. Diverticulitis- has LLQ abdominal pain- however, less likely since no change in bowel habits, nausea, vomiting, fever, etc

Problem List/Plan – 

1. Left Sided Abdominal Pain/ CVA Tenderness- performed pelvic exam. Ordered CBC, BMP, LFT’s and Lipase to rule out any other reasons for pain, check for infection, etc. Give Tylenol for pain relief. Perform transvaginal ultrasound to r/o TOA or cyst.
2. Creamy white vaginal discharge- Take sample of vaginal discharge to check for BV. STI panel to r/o chlamydia. Begin empirical Chlamydia treatment- Ceftriaxone 500 mg once IM, doxycycline 100 mg PO 2x/day
3. Nasal Congestion, cough, sneezing-most likely due to allergies. Prescribe Claritin for relief of symptoms.
4. Obesity-  Educate patient on importance of exercise, healthy eating and diet habits, and the potential dangers and health problems associated with being overweight.
5. Fatigue/ difficulty sleeping- Make suggestions about limiting caffeine intake close to bedtime, sleeping in a quiet room, sticking to a sleep schedule, and increasing physical activity during the day. Discuss with patient any stressors or anxieties keeping her awake and assess whether social worker referral is necessary.