Name: Mrs. R

Sex: Female

Address: Brooklyn, NY

Date of Birth: 5/13/1992, 29 years old

Date & Time: 12/7/21, 10:00 AM

Location: Woodhull Hospital Women’s Health Clinic

Marital Status: Married

Race: Hispanic

Source of Information: Self

Reliability: Reliable

Chief Complaint: LLQ pain x 3 days

History of Present Illness: 

29 y/o Hispanic female G2P1000 LMP 10/23/2021 EGA 6 b3/7 weeks, presents ℅ LLQ abdominal pain x 3 days. Pt states the pain came on suddenly after she lifted a heavy box, and is constant. Pt described the pain as a burning sensation, non-radiating, aggravated by standing and movement and alleviated by rest, rated 4/10 currently. Pt states she never felt pain like this before, denies taking any medications to help with the pain. Pt also admits to current nausea, dizziness, diaphoresis, blurred vision, and SOB. Denies fever, vaginal bleeding, vomiting, diarrhea, constipation, CP, palpitations, shoulder pain, or dysuria.

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: C-section 3 years ago, no complications

Gynecological History

• Denies fibroids, cysts, or endometriosis, hx abnormal paps
• LMP: 10/23/21
• Monogamous, admits to being currently sexually active. Denies history of sexually transmitted infections.

OB History:

Daughter, Age 3, born via C-section, unknown number of weeks and unknown reason, no complications

• Denies history of abortions, miscarriages, or ectopic pregnancy

Medications:

None

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 29 y/o married female. She lives in an apartment with her husband and child.

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

Travel- Denies any recent travel.

Review of Systems:

General – Admits to diaphoresis. 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 dizziness. Denies vertigo or head trauma, unconsciousness, head fracture or coma.

Eyes – Admits to blurred vision. Denies fatigue, lacrimation, photophobia, and pruritus. Last eye exam last January- normal.

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

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

Psychiatric –Admits to current anxiety due to abdominal pain. Denies depression, OCD or ever seeing a mental health professional.

Physical Exam

General: 29 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 anxious and diaphoretic. 

Vital Signs: BP: 94/50, sitting                      

R: 18 breaths/min unlabored     

P:74 beats/min, regular       

T: 97.9 Degrees F (oral)                      

O2 Sat: 98% on Room air

Height: 61 inches            Weight: 109 pounds        BMI: 20.6

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

Thorax & Lungs 

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

Heart-Regular rate and rhythm. No splitting of S2 or friction rubs appreciated. 

Lungs – Clear to auscultation bilaterally..

Abdomen- Tenderness to deep palpation of left lower quadrant. Non-tender to palpation across other quadrants, no guarding or rebound noted, no CVA tenderness Vulva- no lesions, scarring

Vagina- slight milky white discharge, no bleeding

Cervix-non-friable, no cervical motion tenderness

Uterus/adnexa- non-tender, no palpable masses

Assessment

29 y/o Hispanic female G2P1000 LMP 10/23/2021 EGA 6 b3/7 weeks, presents ℅ LLQ abdominal pain x 3 days. Pt also admits to current nausea, dizziness, diaphoresis, blurred vision, and SOB. Upon exam, patients appears anxious and diaphoretic, tender to deep palpation on LLQ of abdomen. 

Differential Diagnoses

1. Ectopic Pregnancy/ Ruptured Ectopic- LLQ abdominal pain, 6 weeks pregnant, dizziness, diaphoresis, hypotension, no vaginal bleeding
2. Muscle Strain- pain came on when lifting
3. Regular Pregnancy Pain
4. Missed Abortion
5. Pelvic Inflammatory Disease
6. Ovarian Cyst/ Ovarian Torsion/ Tubo-ovarian abscess
7. UTI/ pyelonephritis
8. Diverticulitis

Plan:

1. LLQ Pain-Rule out ectopic pregnancy- STAT CBC, BMP, bHCG, transabdominal and transvaginal ultrasound

• If no ectopic, treat with tylenol (no ibuprofen since pregnant) 

2. Dizziness, Diaphoresis, hypotension- make sure patient is seated, give water, juice, ice packs, check glucose levels

Health Maintenance- if IUP visualized, establish prenatal care