Daniel DeMarco             Focused H&P #6            OB/GYN

Chief Complaint: Lower Abdominal Pain

 

History of Present Illness:

NC is a 22yo G0 presenting to the ED with lower abdominal pain. The intermittent pain began last night at 10PM and involves the right and left lower quadrants as well as the suprapubic region. It does not radiate. This morning at 3AM the pain woke her from sleep and has been constant. She describes it as both sharp and crampy. There are no aggravating factors. This is the first time she has experienced this. She currently rates it as a 8/10. LMP 4/17/19 and she is on OCP. Denies fevers, chills, body aches, nausea, vomiting, vaginal bleeding, leakage of fluid.

 

Obstetric History: G0

Gynecologic History: LMP 4/17/19. Regular, monthly periods with 3-5 days of bleeding. On OCP. Denies menorrhagia, history of ovarian cysts, history of fibroids, endometrial polyps, STI, PID, chronic pelvic pain, abnormal PAP smear, GYN cancer.

PMH: Asthma

Medications: Albuterol

PSH: None

Allergies: NKDA

Family History: None

Social History: Never Smoker. Social EtOH. No illicit drug use.

 

Review of Systems:

General : Denies fever, chills, night sweats, loss of appetite, weight loss, weight gain, 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 vomiting, 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: 111/71

Pulse: 73bpm

RR: 18 breaths/min

Temp: 36.8C

SpO2: 96%RA

Ht: 60in.

Wt: 52kg

 

General Survey: Patient holding lower abdomen. Mild 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. No guarding, rebound tenderness. – Rovsing’s. – Psoas. + Obturator.

Vaginal Exam: Normal vulva, vagina. Cervix closed. 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:

144 | 106 | 10     < 93

4.0  | 26  |0.88

 

            13.1

    8.1> 38.6 <217

 

ALT: 15

AST: 18

ALP: 39

Lipase: 51

 

UA: Moderate Leukocyte Esterase. WBC >50. Few Bacteria. 0-4 Squamous Epithelial Cells.

 

Assessment/Plan:

NC is a 22yo G0 presenting to the ED with lower abdominal pain. Ovarian torsion versus Appendicitis versus Ovarian Cyst versus UTI.

 

OB/GYN

#Lower Abdominal Pain – Ovarian Torsion vs. Appendicitis vs. Ovarian Cyst vs. UTI

– STAT Transabdominal and Transvaginal Ultrasound with Doppler. Will help evaluate for Ovarian Torsion or Ovarian Cyst

– Alvarado Score for Appendicitis = 0. Will consider Contrast CT A/P if above ultrasounds are negative

– Start Nitrofurantoin 100mg ER PO q12h x 5d

– Start Acetaminophen 975mg PO q6h prn for pain

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student