Daniel DeMarco               Focused H&P #3              OB/GYN

Chief Complaint: Lower Abdominal Pain Since Last Night

 

History of Present Illness:

NC is a 25yo G4P1111 at 28w6d with EDD 7/29/19. She presents with complaint of sharp abdominal pain that began at 9:30PM last night while she was resting. She points to the area encompassing her left and right lower quadrants as well as the suprapubic region. The pain has been constant and has worsened in severity. She rates the pain a 7/10. This is the first time she has experienced this in any of her pregnancies. Endorses fetal movement. Denies leakage of fluid, vaginal bleeding, contractions, fever, chills, nausea, vomiting.

 

Obstetric History: Full Term NSVD x 1, Midtrimester loss x 1 associated with suspected cervical insufficiency – Preterm Premature Rupture of Membranes, Medical termination in first trimester

Gynecologic History: None

PMH: None

Medications: Prenatal Vitamins

PSH: Cervical Cerclage (1/24/2019)

Allergies: NKDA

Family History: Father and Mother living with no known medical problems

Social History: Never smoker. No EtOH use. No illicit drug use. Admits sexual activity with male partners. Patient denies sexual intercourse since cerclage placement.

 

Review of Systems:

General : Admits weight gain. Denies fever, chills, night sweats, loss of appetite, weight loss, weakness, fatigue

Skin, Hair, Nails : Denies change in texture, excessive dryness or sweating, discolorations,

pigmentations, moles, rashes, pruritus, change in hair distribution

Head : Denies trauma, unconsciousness, coma, fracture, vertigo, headache

Eyes : Denies corrective lenses, visual disturbances, fatigue, photophobia, pruritus, lacrimation, vision changes

Ears : Denies deafness, pain, discharge, tinnitus, hearing aids

Nose/Sinuses : Denies discharge, epistaxis, rhinorrhea, congestion

Mouth/Throat : Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes,

dentures

Neck : Denies lumps, swelling, stiffness, decreased range of motion

Breast : Denies lumps, nipple discharge, pain

Respiratory : Denies dyspnea, shortness of breath, wheezing, cough, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea

Cardiovascular : Denies palpitations, irregular heartbeat, edema, syncope, chest pain, known heart murmur

Gastrointestinal : Admits abdominal pain. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructations, diarrhea, constipation, hemorrhoids, change in stool caliber, blood in stool

Genitourinary : Denies change in frequency, urgency, hesitancy, dribbling, nocturia, polyuria,

oliguria, dysuria, change in urine color, incontinence, flank pain

Musculoskeletal : Denies joint pain, deformity, swelling, redness, arthritis

Peripheral Vascular : Denies intermittent claudication, coldness or trophic changes, varicose veins, color change, edema

Hematologic : Denies anemia, easy bruising/bleeding, lymph node enlargement, history of

DVT/PE

Endocrine : Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism

Neurologic : Denies seizures, loss of consciousness, sensory disturbances, paresthesia,

dysesthesia, hyperesthesia, ataxia, loss of strength, change in mental status, memory loss,

asymmetric weakness

Psychiatric : Denies feelings of helplessness, feelings of hopelessness, lack of interest in usual

activities, suicidal ideation, anxiety

 

Physical Exam:

Vital Signs:

BP: 111/65

Pulse: 78bpm

RR: 18 breaths/min

Temp: 36.8C

SpO2: 100%RA

Ht: 68 in.

Wt: 80.1kg

 

General Survey: Patient lying comfortably in bed. No apparent distress.

Skin: No petechiae, masses, lesions. Warm, moist.

Hair: Average quantity and distribution.

Nails: Capillary refill <2s throughout.

HEENT: Head: NC/AT. Non-tender to palpation throughout. Eyes: PERRLA. EOMs intact.

Cardiovascular: Regular rate and rhythm. S1 and S2. No murmurs, gallops, rubs.

Chest and Pulmonary: Symmetrical rise and fall of chest wall. No labored breathing, accessory muscle use. Clear to auscultation bilaterally. Nontender to palpation throughout.

Abdomen: Fundal Height measures 28cm. Soft, BS + and normoactive throughout. Non-tender to palpation throughout. No guarding, rebound tenderness.

Vaginal Exam: C/L/P, cerclage in place. No fluid in the vaginal vault.

Extremities and Peripheral Vascular: Upper and Lower extremities symmetrical. No edema of bilateral upper and lower extremities. Peripheral pulses 2+.

 

Cardiotocography: Baseline 140bpm, moderate variability, + acceleration, no decelerations;

Category I FHT; contractions q2-3min

Fetal U/S: Vertex, Posterior Placenta, AFI = 17cm

 

Assessment/Plan:

NC is a 25yo G4P1111 at 28w6d with EDD 7/29/19 complaining of abdominal pain. Likely dehydration versus Preterm Labor.

 

OB/GYN

#Abdominal Pain at 28w6d

• Fetal Fibronectin to r/o Preterm Labor
• NS at 50cc/hr
• Continuous cardiotocography
• CBC, BMP, T&S, Coags
• Observe patient for two hours. Plan for reexamination at that point. If FFN negative and abdominal pain resolved, plan to discharge home with low threshold for return to ED (if recurrence of pain, vaginal bleeding, leakage of fluid, decreased fetal movement). If discharged, patient will keep scheduled appointment/follow up on Tuesday in High Risk Clinic

 

DVT Prophylaxis with Intermittent Pneumatic Compression

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student