Toor Noori

H&P 1

Location: QHC: OBGYN (L&D)

Date: 11/18/2019

Source of Info: self

CC: “ Abdominal pain and vaginal bleed x 4 days”

HPI

21 y/o G2P1001, LMP reported last weeks of 10/2019 (exact date unknown), presents to the ED with c/o lower abdominal pain and vaginal bleed x 4 days. Pt states this is her third visit to the ED, since 11/13/2019. Her first visit was here at QHC ED (11/13/2019) during which she was evaluated for the same complaint. Her BHCG on 11/13/2019 was 4,228 and ultrasound showed Intrauterine gestational sac without yolk sac and fetal pole. Her second visit was to NYHQ ED where she was once again evaluated for similar complaint. At the time she was discharged with a diagnosis of a threatened abortion. Today she c/o worsening pain and increase in bleeding (uses about 7 pads today). She states she passed large clots of blood from her vagina earlier today but did not witness passing of any tissue like substance. Denies any trauma, fever, chills, urinary symptoms, CP, SOB, dizziness, palpitations, headaches, visual disturbances,

Differential Diagnosis 

Threatened abortion

Incomplete abortion

Missed abortion

PMH

none

Immunizations

Up to date

Past surgical hx

none

Past hospitalizations

none

Medications

none

Allergies

No known medication, food or seasonal allergies

Family history

No sig family hx

Social hx

Lives at home with boyfriend and 2year old daughter.

Denies hx of smoking cigarettes, illicit drug use or alcohol consumption.

GYN hx

• 1 NSVD, delivered full term, 2016, girl, wt: 2807g
• Denies any other complications during prior pregnancies
• Clinic patient
• No hx of cysts, fibroids, STIs, PID, or abnormal PAP smears.
• Denies any Hx of breast/uterus/ovarian/colonic malignancies

ROS

General 

• denies generalized weakness/fatigue, loss of appetite, recent weight loss or gain, fever or chills, or night sweats

Head 

• denies HA, vertigo

Eyes 

• denies visual disturbance

Pulmonary System

• denies cough, SOB, DOE, orthopnea, wheezing, hemoptysis, cyanosis, or PND

Cardiovascular System

• denies CP, HTN, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur

Gastrointestinal System

• positive for lower abdominal pain and vaginal bleed x 4 days; denies loss of appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructations, abdominal distention, constipation, diarrhea, change in bowel habit, hemorrhoids, or melena

Genitourinary System 

• denies urinary urgency, hematuria, urinary frequency, flank pain, nocturia, oliguria, polyuria, dysuria, incontinence, or awakening at night to urinate

Physical Exam

General appearance

Alert, cooperative, appears stated age, well-developed, well-groomed and well-nourished. Appears to be in no apparent distress.

Vitals:

BP : 112/72

HR :83 Bpm

RR :18 breath per min

Temp : 97.6F

SpO2 :98% room air

Head – normocephalic and atraumatic

Lungs – clear to auscultation bilaterally, respirations unlabored, no adventitious sounds

Heart – regular rate and rhythm, S1 and S2 normal, no murmur, rub or gallop

Abdomen – soft, non-tender to palpation, no rebound or guarding pain, bowel sounds active in all four quadrants, no masses, no organomegaly, no CVA tenderness

Pelvic exam – cervix multiparous, 1cm cervix dilated, moderate blood in vaginal vault; uterus 10 weeks in size- anteverted- non-tender, adnexa non-tender with no masses, no cervical motion tenderness.

Bedside sonogram:

Irregular appearing intrauterine gestational sac with not yolk sac or fetal pole. Unremarkable adnexa B/L

LABS:

BHCG: 1406

140 | 100| 9

——————–<76

4.2| 25| .62

WBC: 8.89 / Hb:11.8  HCT: 38.9/ PLT: 309 AST: 15 ALT: 11

Assessment:

Incomplete abortion

Plan:

-Manual vacuum aspiration (per patient’s decision after she was counseled on the options available to her.)

– Send specimen to pathology after vacuum aspiration.

– Prescribe Naproxen 500 mg BID and Doxycycline 100mg BID x 7 days as per GYN team.

– F/U in GYN clinic in 2 weeks

– Return to the ED if any of the following occurs: fevers/chills, heavy bleeding, or extreme pain.