Daniel DeMarco           Focused H&P #4            OB/GYN

Chief Complaint: Vaginal Bleeding

 

History of Present Illness:

CE is a 16yo G1P0000 at 12w6d (12) with EDD 11/20/19. Her LMP was in mid-January (patient cannot remember exact date). She was receiving prenatal care at MIC Women’s Health Services, though she has not been taking prenatal vitamins. She is “unsure” if the pregnancy is desired. Her menstrual periods are monthly, regular, and last 3-4 days. She presents with complaint of vaginal bleeding that began 3 days ago. She states that the vaginal bleeding increased in severity today, and that she is using three to four fully soaked pads per day. She endorses crampy lower abdominal pain that began today. Denies leakage of fluid, nausea, vomiting, fever, chills, dysuria, dyspareunia.

 

Obstetric History: None

Gynecologic History: Monthly menses, regular 3-4d long. History of Chlamydia infection 9/19/18. Denies history of fibroids, endometrial polyps, PID, GYN cancer

PMH: None

Medications: None

PSH: None

Allergies: NKDA

Family History: None

Social History: Never smoker. No EtOH use. No illicit drug use. Admits sexual activity with male partner. Last intercourse 3d ago.

 

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 : Admits vaginal bleeding. 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: 122/74

Pulse: 100bpm

RR: 18 breaths/min

Temp: 36.8C

SpO2: 100%RA

Ht: 64in.

Wt: 59kg

 

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: Soft, nondistended, BS + and normoactive throughout. Non-tender to palpation throughout. Fundus palpated just above pubic symphysis. No guarding, rebound tenderness.

Vaginal Exam: Normal vulva, vagina. Cervix closed. Vagina with some blood, no clots. No active bleeding. No adnexal masses, tenderness.

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

 

Labs:

135 | 98 | 6     < 84

4.3  | 22 |0.52

 

           12.0

   7.9> 35.7 <230

 

ALT: 10

AST: 13

ALP: 76

 

B-hCG: 47,493

 

Normal UA

 

Imaging:

Transabdominal Pelvic Sonogram: Examination shows about 12 weeks and 6 days of IUP. Fetal heart moments were seen and noted to be 160bpm. No adnexal mass seen.

 

Assessment/Plan:

CE is a 16yo G1P0000 at 12w6d (12) with EDD 11/20/19 complaining of vaginal bleeding and abdominal cramping. Likely threatened abortion.

 

OB/GYN

#Threatened Abortion at 12w6d with EDD 11/20/19

• T&S to determine Rh status. If Rh negative, will administer Rhogam
• Start Prenatal Vitamins 1 pill PO qd
• Start Iron Supplement 30mg PO qd

• Patient wishes to transfer care to QHC clinic. Information and phone number given. She will contact to schedule appointment for next week. Will obtain records from MIC Women’s Health Services
• Repeat Pelvic U/S next week
• Repeat B-hCG next week
• Patient advised to avoid vigorous activity, heavy lifting, and sexual intercourse
• Patient counseled about the risk of miscarriage and other adverse outcomes in pregnancy. Advised to return to ER if worsening abdominal cramping, increase in vaginal bleeding, passage of products of conception, fever, chills, nausea, vomiting
• Discussed options and R/B/A for TOP should she decide on this

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student