Name: Mrs. S

Sex: Female

Address: Brooklyn, NY

Date of Birth: 10/11/1983, 38 years old

Date & Time: 11/29/21, 3:30 PM

Location: Woodhull Hospital Women’s Health Clinic

Marital Status: Married

Race: Hispanic

Source of Information: Self

Reliability: Reliable

Chief Complaint: pelvic pain x 2 weeks

History of Present Illness: 

38 y/o Hispanic female G4P3013 presents ℅ pelvic pain. Patient states that the pain began 2 weeks ago before her period, is constant, and has not been worsening nor improving. Patient describes the pain as a “pinching pain” generalized in her pelvic area, non-radiating, and rates pain as 7/10. States she has never had pain like this before. Denies any aggravating or alleviating factors, denies taking anything for the pain. Patient also states that she has headaches associated with nausea and vomiting which began one year ago when she started taking her OCP’s. Pt denies changes in vaginal bleeding (increased/ decreased), vaginal discharge/ itchiness, dysuria, diarrhea, constipation, abdominal pain. 

Past Medical History:

Present medical illnesses – none

Past Illnesses- none

Childhood illnesses – none

Immunizations – Up to date

Screening Tests- none

Blood Transfusions- none

Past Surgical History: none

Gynecological History

• Denies fibroids, cysts, or endometriosis, hx abnormal paps
• LMP: 11/13/21
• Monogamous, admits to being currently sexually active. Denies history of sexually transmitted infections.

OB History:

Son- age 12, alive and well, born at 40 weeks gestation, NSVD no complications

Daughter- age 7, alive and well, born at 38 weeks gestation, NSVD no complications

Daughter- age 5, alive and well, born at 37 weeks gestation, NSVD, no complications

• Denies hx C-section, surgically treated abortions, admits to one miscarriage at 6 weeks, treated medically

Medications:

Ethinyl Estradiol/ Norgestimate (Tri-Sprintec), 1 tab PO Qd as indicated in pack

Allergies:

No known food, drug, or environmental allergies.

Family History:

No family history of gynecologic cancers: breast, ovarian, endometrial, cervical cancer

Social History:

Mrs. S is a 38 y/o married female. She lives at home with her husband and 3 children.  

Habits –Denies ETOH use, smoking, e-cigarettes or illicit drug use. 

Travel- Denies any recent travel.

Review of Systems:

General – Denies loss of appetite, recent weight loss or gain, current generalized weakness, fatigue, fever, chills, or night sweats.

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

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

Eyes – Denies visual disturbances, fatigue, lacrimation, photophobia, and pruritus. Last eye exam last January- normal.

Pulmonary system – Denies dyspnea, shortness of breath, cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, cyanosis or hemoptysis.

Cardiovascular system –  Denies chest pain, palpitations, irregular heartbeat, syncope or known heart murmur.

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

Genitourinary system –Admits to pelvic pain. Denies urinary frequency, urgency, polyuria, oliguria, nocturia, incontinence, dysuria, hesitancy, dribbling, or flank pain.

Psychiatric –Denies depression, anxiety, OCD or ever seeing a mental health professional.

Physical Exam

General: 38 year old female, alert and oriented to person, place and time. Patient is of average build, is well dressed, well groomed, and has good hygiene. Patient appears in no acute distress. 

Vital Signs: BP: 114/68, sitting                      

R: 16 breaths/min unlabored     

P:84 beats/min, regular       

T: 97.9 Degrees F (oral)                      

O2 Sat: 98% on Room air

Height: 66 inches            Weight: 150 pounds        BMI: 24.2

Skin- Warm and moist, smooth, good turgor, nonicteric. No lesions, masses, scars, tattoos, thicknesses or opacities.

Thorax & Lungs 

Chest – Symmetrical, no deformities, no evidence of trauma. Respirations are unlabored, no paradoxical respirations or use of accessory muscles noted. 

Heart-Regular rate and rhythm. No splitting of S2 or friction rubs appreciated. Carotid pulses are 2+ bilaterally without bruits.

Lungs – Clear to auscultation bilaterally. Chest expansion and diaphragmatic excursion symmetrical.

Abdomen- Tenderness to palpation to left suprapubic area. Non-tender to palpation across abdominal quadrants, no guarding or rebound noted, CVA tenderness negative 

Breast- non-tender to palpation, no masses, lesions, or discharge noted.

Vulva- no lesions, scarring

Vagina- no vaginal bleeding/ abnormal discharge

Cervix-non-friable, no blood or discharge extruding from os

Uterus- non-tender, no palpable masses

Adnexa- tender to palpation on left side, non-tender on right side, no palpable masses

Assessment

38 y/o Hispanic female G4P3013 presents ℅  pelvic pain for the past 2 weeks. Pt endorsed tenderness to palpation on left pelvic area on abdominal exam and in left adnexal area on bimanual vaginal exam.

Differential Diagnoses

1. Pelvic Inflammatory Disease
2. TOA
3. Ovarian Torsion
4. Ovarian Cyst
5. Diverticulitis
6. Appendicitis
7. Urinary Tract Infection

Plan: 

1. Left Pelvic Pain- obtain ultrasound, take pain medications such as ibuprofen
2. Headaches, nausea, vomiting-discontinue tri-lo-sprintec. Discuss alternative contraception options with patient, including IUD, injection, and implant

Health Maintenance- Annual health well women’s visit scheduled in a few months