Identifying Data:

Full Name: MMR

Address: Manhattan, NY

Date of Birth: xx/xx/1992

Date & Time: 5/31/2022

Source of Information: Self

Reliability: Reliable

Chief Complaint: vaginal bleeding for 2 weeks

History of Present Illness:

30-year-old female with PMH of HTN, G1P0 at 7w2d presents to the ED with vaginal bleeding for the past 2 weeks. Patient has been using 2 pads a day. She notices some passage of clots but no passage of tissue. Patient also reports mild suprapubic abdominal pain for 4 days. Patient states the pain is intermittent and cramping in nature, non-radiating, at a severity of 4/10. Pain is relieved with Tylenol and is made worse by standing and walking. LMP was 4/10/22. She has not received any prenatal care since knowing the pregnancy. Denies history of fibroids, ovarian cysts, and STIs. Denies recent trauma, dysuria, hematuria, nausea, vomiting, fever, chills, chest pain and SOB.

Past Medical History:

Hypertension

Past Surgical History:

Denies past surgical history

Medication:

Lisinopril (Zestril) 40mg PO daily

Allergies:

NKDA

Family History:

Father – Prostate cancer

Mother – Hypertension

Social History:

Habits: Denies alcohol, tobacco and illicit drug use.

Travel: Denies recent travel.

Home: Living with husband. Independent in all ADLs and IADLs.

Review of System:

General –Denies decreased appetite, recent weight change, fever, and night sweats

Skin – Denies moles, change of skin texture, sweating, itchiness.

Head – Denies headache, light-headedness, recent head trauma.

Eyes – Denies visual changes.

Ears – Denies tinnitus, deafness, pain.

Nose – Denies discharge, obstruction, epistaxis.

Mouth/throat – Denies sore throat, mouth ulcers, voice change.

Pulmonary system – Denies SOB, sputum, wheezing.

Cardiovascular system –Denies chest pain, palpitation, syncope.

Gastrointestinal system – Admits to abdominal pain. Denies nausea, vomiting, diarrhea

Genitourinary system – Admits to vaginal bleeding. Denies urinary frequency, urgency, and oliguria.

Nervous system – Denies seizure, weakness, sensory disturbances, and memory change.

Musculoskeletal system – Denies joint pain, back pain, muscle pain.

Endocrine system – Denies polydipsia, polyphagia, heat intolerance, or excessive sweating.

Psychiatric –Denies history of depression, anxiety, suicidal thoughts, hallucination, and obsessive/compulsive disorder.

Physical Examination:

Vitals:

Temp: 98.6 F, oral

BP: 127/95, LA, sitting

Pulse: 96, regular

RR: 18/min, unlabored

O2 saturation: 100% room air

Ht: 5’2’’ in

Wt: 132 lb

BMI: 23.55  kg/m2

General – AAO X3. Appears uncomfortable. Not in acute distress. Not diaphoretic. Appears her stated age. Well developed and well groomed.

Skin –Skin iswarm and dry, good turgor. No jaundice.

Hair – Average quantity and distribution

Nails – No clubbing, capillary refill <2 seconds on fingers and toes.

Head – Normocephalic, atraumatic.

Ears – Symmetrical and appropriate in size. No lesions, masses, trauma on external ears.

Eyes – Symmetrical OU. EOMs intact with no nystagmus. No pallor, or scleral icterus.

Oropharynx – Moist, no erythema, no exudates, no masses/lesions. Uvula midline and rises symmetrically with phonation.

Neck – Supple. No JVD. No lymphadenopathy. No cervical adenopathy noted.

Lungs–Clear to auscultation bilaterally, no wheezes/rhonchi/rales.

Heart – RRR, no murmurs, gallop or rubs.

Abdomen – Tender to palpation in the suprapubic and LLQ, with voluntary guarding. No rebound, no palpable masses. Abdomensoft, non-distended, BS present.

Pelvic – Normal external genitalia. No lesions or prolapse of vaginal walls. Cervix visually closed, cervical bleeding present. Tenderness over left adnexa. No cervical motion tenderness.

Musculoskeletal – Full range of motion of lower extremities.

Neurologic – Sensation intact to touch in bilateral upper and lower extremities.

Peripheral Vascular – Extremities are symmetric in color, size, and temperature. No lymphadenopathy.

DDx:

• Ectopic pregnancy
• Spontaneous abortion
• Ovarian torsion
• UTI

Assessment:

30-year-old female G1P0 with PMH of HTN presents with vaginal bleeding for 2 weeks and suprapubic pain for 4 days. Patient appears uncomfortable. Vitals within normal limits. Physical exam revealed bleeding and closed cervical os, suprapubic and LLQ tenderness. Likely ectopic pregnancy vs. spontaneous abortion. Need to r/o ovarian torsion.

Plan:

• Labs:
  • CBC w/diff
  • BMP
  • PT/PTT
  • HCG
  • Hepatic function panel
  • Type and screen
  • UA
• Imaging:
  • Transvaginal pelvic US
• Tylenol 1000 mg PO
• OB consult
• Reassess