Identifying Data:

Full Name: CR

Address: Queens, NY

Date of Birth: xx/xx/1990

Date & Time: 9/11/2022

Source of Information: Self

Reliability: Reliable

Chief Complaint: abdominal cramp and vaginal bleeding x 2 days

History of Present Illness:

32 y.o. G2P1001 currently pregnant at 12 weeks and 6 days with LMP 6/13/22 presented to ED c/o abdominal cramps and vaginal bleeding for 2 days. The cramp started yesterday around 3pm, and patient first noticed some spotting after she went home from work at 5pm. The pain was intermittent, at a severity of 3/10, localized to the suprapubic area. Patient did not take anything for the pain. Nothing makes the pain better or worse. She reported the cramps became more severe and constant this morning, at an intensity of 5/10, with heavier vaginal bleeding. She stated she saturated 2 pads today, didn’t see tissue passed. This is a desired pregnancy. Pt had positive home pregnancy test on 8/20, that’s how she found out about this pregnancy.

Of note, she had her first prenatal visit 3 days ago, blood work was done, unaware of the results; sonogram was done, but was told “it may be too early to see the pregnancy.” Denied dysuria, nausea, vomiting, lightheadedness, fever, and chills.

Past Medical History:

Denied PMH

OB History:

Full term NSVD x 1 in 2008

GYN History:

LMP 6/13/22

Menses are regular, every 32 days. Period lasts 6 days.

Last pap smear was 2019, normal.

Denied history of fibroids, ovarian cyst, STI, PID, abnormal pap smear.

Past Surgical History:

Denied past surgical history

Medication:

• Prenatal vitamin PO, 1 tab daily
• Iron 325 mg PO, daily
• Folic acid 400 mg PO, daily

Allergies:

NKDA

Denied food or environmental allergy

Family History:

Denied family history of gynecologic, breast or colon cancer

Social History:

Habits: Denied alcohol, tobacco and illicit drug use.

Travel: Denied recent traveling

Marital History: Married

Sexual History: Sexually active with 1 male partner. Does not use contraceptives.

Home: Patient lives with husband and her son. Independent in all ADLs and IADLs at baseline.

Review of System:

General –Denied change in appetite, recent weight change, fatigue, fever, and night sweats

Skin – Denied moles, change of skin texture, itchiness.

Head – Denied headache and recent head trauma.

Eyes – Denied visual changes.

Ears – Denied deafness, pain, or use of hearing aids.

Nose – Denied discharge, obstruction, epistaxis, loss of smell.

Mouth/throat – Denied sore throat, bleeding gum, mouth ulcers, voice change.

Pulmonary system –Denied SOB, sputum, orthopnea, wheezing, hemoptysis, and cyanosis.

Cardiovascular system – Denied chest pain or palpitation.

Gastrointestinal system – Admitted to abdominal pain. Denied constipation, diarrhea, and hemorrhoids.

Genitourinary system – Admitted to pelvic pain and vaginal bleeding. Denied urinary frequency, urgency, oliguria and incontinence.

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

Musculoskeletal system – Denied back pain, muscle pain.

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

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

Physical Examination:

Vitals:

Temp: 98.7 F, oral

BP: 129/73

Pulse: 77, regular

RR: 18, unlabored

O2 saturation: 98% room air

BMI: 22.13

General – AAO X3. Not in acute distress. Patient is sitting in bed. Able to speak in full sentences. Appears her stated age.

Skin –Warm and dry, good turgor, no jaundice.

Hair – Average quantity and distribution.

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

HEENT – Normocephalic, atraumatic, external ears normal, no periorbital edema, anicteric, conjunctivae pink, EOMI, oral mucosae moist.

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

Chest – Symmetrical, no deformities. Respirations unlabored, no paradoxic respirations or use of accessory muscles noted. Non-tender to palpation throughout.

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

Heart – RRR, no murmurs, click or rubs.

Abdomen – Lower abdomen is tender to palpation. No rebound or guarding. Abdomen soft, non-distended. BS present. No CVA tenderness.

Pelvic exam –

• Normal perineum.
• Speculum: Blood and large piece of tissue in vagina, no active bleeding from cervical OS.
• Bimanual: cervical os is open. Uterus 6 week sized, soft, mobile, non-tender, bilateral adnexal non-tender, no mass.

Musculoskeletal – FROM of upper and lower extremities.No leg swelling, tenderness, erythema, or warmth b/l.

Neurologic – Awake, alert and follows commands, no focal motor deficit. Sensation intact to touch in bilateral upper and lower extremities. No dysmetria on finger-to-nose bilaterally.

Peripheral Vascular – Pulses are 2+ bilaterally in upper and lower extremities.

Labs and imaging:

• WBC: 9.88
• Hemoglobin: 12.8
• Hematocrit: 38.9
• Platelet: 387

• B-HCG: 16,808
• Rh +
• BMP WNL
• UA: moderate leukocyte, positive nitrite, WBC 21-50

• Pelvic sono:
  • Transabdominal: The examination shows the uterus to measure 10.4 x 5.4 x 6.6 cm. There is a single intrauterine saclike structure measuring 2.2 x 1.2 x 1.5 cm with a mean sac diameter of 1.6 cm. would be consistent with a gestational age of 6 weeks 0 days. The internal contents of this structure are not adequately characterized however. The ovaries measure approximately 3.3 x 1.6 x 2.5 cm on the left and 2.5 x 1.5 x 2.2 cm on the right. Flow noted to both ovaries. No significant pelvic free fluid.

• Transvaginal: There is a single intrauterine gestational sac like structure measuring 2.5 x 1.3 x 1.8 cm with a mean sac diameter of 1.8 cm, which would be consistent with a gestational age of 6 weeks 2 days. There are nonspecific echogenic structures within the sac without definite heartbeat/color Doppler at the time of imaging. Cervical Nabothian cysts. The ovaries measure approximately 3.2 x 1.4 x 1.6 cm on the left and 3.1 x 2.1 x 2.2 cm on the right. Flow noted to both ovaries. Minimal pelvic free fluid.

• Bedside sono: Uterus 6 x 6 x 5cm, endometrial stripe 7mm, bilateral adnexa no mass, no free pelvic fluid.

DDx:

• Complete abortion
• Incomplete abortion

Assessment and Plan:

32 yo G2P1001 at 12w6d presented with abdominal cramps and vaginal bleeding for 2 days. Pelvic exam revealed blood and a large piece of tissue in the vagina. Os is open, no active bleeding. Bedside sono did not show gestational sac, likely complete abortion.

#Abdominal cramp and vaginal bleeding, likely complete abortion

– tissue sent to pathology

– Tylenol 975 mg every 8 hours as needed for pain

– discharge home, f/u with GYN annually or PRN

– advised patient to come to ED if vaginal bleeding more than period, saturated 1 pad/hour for continuous 3 hours, abdominal pain not relieved by Tylenol 975 mg every 8 hours, fever, chills, shortness of breath, chest pain, dizziness, palpitation

#UTI

– urine culture

– Cefpodoxime 100 mg twice daily for 10 days