Daniel DeMarco           Focused H&P #5           OB/GYN

Chief Complaint: Low Back Pain, Abdominal Pain, Vaginal Pressure, Vomiting, and Diarrhea

 

History of Present Illness:

DW is a 25yo G5P1031 at 34w6d (d,7) with EDD 6/19/19. She presents with one week complaint of low back pain, lower abdominal pain, and vaginal pressure. She states that it comes and goes, but got very severe last night and today. Yesterday, she experienced three episodes of vomiting, though she states that she has experienced a lot of vomiting and reflux throughout her pregnancy. Additionally, she endorsed three episodes of diarrhea yesterday. Today, she experienced an additional three episodes of vomiting but no diarrhea. She denies fevers, chills, body aches, vaginal bleeding, leakage of fluid, or decreased fetal movement.

 

Obstetric History: Full Term NSVD x 1 (2014), SAB x 1 (5/2017), Ectopic x 2 (MTX 6/2017, R Salpingectomy 5/2018)

Gynecologic History: LMP 09/29/2018. Denies history of fibroids, endometrial polyps, PID, GYN cancer

PMH: None

Medications: Prenatal Vitamins, Iron

PSH: R Salpingectomy (5/2018)

Allergies: NKDA

Family History: Mother, Living, DM2. Maternal Grandmother, Living, Asthma.

Social History: Former Occasional Smoker, Quit 3y ago. No EtOH use. No illicit drug use. Admits sexual activity with one male partner. Last intercourse 5 months 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, vomiting. Denies change in appetite, intolerance to specific foods, nausea, dysphagia, pyrosis, flatulence, eructations, diarrhea, constipation, hemorrhoids, change in stool caliber, blood in stool

Genitourinary : Denies vaginal bleeding, 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: 102/58

Pulse: 107bpm

RR: 18 breaths/min

Temp: 37.1C

SpO2: 100%RA

Ht: 64in.

Wt: 86.2kg

 

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 is 35cm. Soft, nondistended, BS + and normoactive throughout. Non-tender to palpation throughout. No guarding, rebound tenderness.

Vaginal Exam: C/L/P. Normal vulva, vagina. 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:

137 | 102 | 5     < 71

4.5  | 20  |0.70

 

            9.5

 15.3> 30.6 <404

 

ALT: 9

AST: 14

Lipase: 37

Amylase: 99

 

Normal UA

 

Fetal Heart Tracing: 135bpm, moderate variability, positive accelerations, variables; Category II Tracing

Tocometry: Uterine irritability

Sonogram: Vertex, AFI: 9cm, Left Lateral Placenta, BPP 8/8

 

Assessment/Plan:

DW is a 25yo G5P1031 at 34w6d (d,7) with EDD 6/19/19 with complaint of low back pain, lower abdominal pain, vaginal pressure, vomiting, and diarrhea. Likely Gastroenteritis. Patient admitted due to Category II tracing.

 

OB/GYN

#Category II Tracing at 34w6d (d,7) with EDD 6/19/19

– Continuous Cardiotocography

– Sonogram and BPP in AM

– CBC, BMP in AM

 

GI

#?Gastroenteritis

– NS at 50cc/hr

– Regular Diet

– Acetaminophen 500mg Tablet PO q6h PRN for abdominal pain

 

DVT Prophylaxis with Intermittent Pneumatic Compression

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student