Daniel DeMarco             Focused H&P #7           OB/GYN

Chief Complaint: Vaginal Bleeding x 3 months

 

History of Present Illness:

AT is a 27yo G4P2022 with LMP mid-January 2019. Her GYN history is significant for PAP revealing ASCUS and HPV+ in 2016 for which she underwent colposcopy and biopsy which revealed CIN3. Numerous attempts were made to contact the patient for follow up LEEP, though she was lost to follow up. She presents with complaint of vaginal bleeding x 3 months which has worsened in severity. She is currently utilizing 6 fully soaked pads per day. She states that most days of the month she experiences vaginal bleeding, and the longest time frame which she didn’t experience bleeding was for one week. She came in today because she experienced “discomfort” that woke her up from sleep, at which point she noticed a blood clot the “size of my [her] hand.” She endorses dyspareunia. Denies weakness, lightheadedness, shortness of breath, abdominal pain, vaginal fullness, dysuria, fever, chills, nausea, vomiting.

Patient reports that she was seen at Choices Clinic in December 2018 during which a PAP smear was performed. Per patient, they wanted to perform colposcopy and biopsy, though the patient refused.

 

Obstetric History: Full Term NSVD x 2 (2013, 2014), TOP x 2 (MTX 2017, 2018)

Gynecologic History: LMP mid-January 2019, date unknown. Had been using NuvaRing after her pregnancy in 2014. She was having regular, monthly periods with 5-6 days of bleeding. 2016 PAP with ASCUS and HPV+. Colposcopy and biopsy showed CIN3. History of Gonorrhea/Chlamydia infection (2007)

PMH: Back Pain

Medications: Aspirin 325mg PO q4h prn

PSH: None

Allergies: Peanuts – Hives. Denies ever requiring hospitalization, epinephrine, or intubation.

Family History: Mother, Living, HTN. Maternal Grandmother, Living, HTN. Maternal Grandfather, Living, HTN.

Social History: Never smoker. Social EtOH use. No illicit drug use. Admits sexual activity with one male partner. Last intercourse “months ago.”

 

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

Genitourinary : Admits vaginal bleeding, dyspareunia. 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: 130/80

Pulse: 114 bpm

RR: 18 breaths/min

Temp: 36.9C

SpO2: 100%RA

Ht: 68in.

Wt: 68kg

 

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. No guarding, rebound tenderness.

Vaginal Exam: Normal vulva, vagina. Old blood noted in the vaginal vault with minimal active bleeding. Cervix grossly abnormal with exophytic mass. Upon palpation, measures approximately 5x6cm, hard, nontender, cervical mass. No adnexal masses, tenderness. No mass appreciated in rectum.

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

 

Labs:

139 | 104 | 11     < 117

4.1  | 26  |0.78

 

            11.4

 11.5 > 35.3 < 340

 

ALT: 9

AST: 14

ALP: 80

 

PTT: 28.4

PT: 11.3

INR: 1.0

 

Normal UA

 

Assessment/Plan:

AT is a 27yo G4P2022 with LMP mid-January 2019 and GYN Hx significant for ASCUS, HPV + and CIN3 (2016) with complaint of Vaginal Bleeding x 3 months. Likely secondary to cervical mass.

 

OB/GYN

#Vaginal Bleeding x 3 months. Likely secondary to cervical mass. ?Cervical Cancer

– Two cervical biopsies were performed at the 12 o’clock and 3 o’clock positions. Consent was obtained and R/B/A were discussed prior to procedure

– Transvaginal Sonogram

– Repeat CBC, T&S

– Reiterated the importance of follow up. Confirmed patient’s phone number in medical record. Will contact her once pathology is available

 

Musculoskeletal

#Back Pain – Stable

– In light of vaginal bleeding, advised patient to D/C Aspirin

– Start Acetaminophen 975mg 1 tablet PO q6h prn

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student