H&P #1

Identifying Data

Full Name: R.R

Sex: Female

DOB: xx/xx/1999

Date & Time: October 17, 2023

Location: Metropolitan Hospital

Source of Information: Self

Reliability: Reliable

Source of referral: Self

Mode of transportation: Taxi

 

Chief Complaint: “vaginal bleeding” x 3 days

 

History of Present Illness:

24 y/o G3P2 female presents to the ED c/o vaginal bleeding s/p mechanical fall x 3 days. Patient states she works as a cleaner and was cleaning the floor when she slipped and fell, landing on her buttocks. Since fall patient endorses vaginal bleeding with 4 large clots that has recently been improving. States she was previously changing sanitary napkins q3H but today bleeding is minimal and only requires a liner. Endorses abdominal pain that “feels like something is tearing from my uterus.” Patient rates pain 8 out of 10 in severity, pain does not radiate. Patient states she took an at home pregnancy test 1 week ago which was positive. States this is a desired pregnancy. Patient has not yet seeked prenatal care. Patient has not used any OTC products for pain. Denies head trauma, LOC, fever, chills, body aches, nausea, vomiting, dizziness, vaginal discharge, dysuria, urinary urgency/frequency.

LMP: 8/30

 

Differential diagnosis:

  1. Bleeding 2/2 trauma
  2. Spontaneous Abortion
  3. Ectopic pregnancy

 

Past Medical History

Medical History:

  • No past medical history
  • No past hospitalizations or history of blood transfusions.

Medications:

  • No prescription medication use.
  • Denies herbal supplement use.

Surgical History:

  • No past surgical history.

Allergies:

  • No known drug/food/environmental allergies

Family History:

  • Mother: Age 50s, alive and well.
  • Father: Age 50s, alive and well.
  • 2 daughters, alive and well. Full term, NSVD x 2.
  • No known family hx cardiac disease, cancer.

Social History:

  • Smoking: Never
  • Alcohol: Never
  • Denies past or current illicit drug use
  • Marital History: Married
  • Language: Patient requires Spanish translation
  • Occupational History: Cleaner
  • Travel: No recent travel
  • Home situation: Lives in Queens apt with husband and 2 daughters
  • Sleep: Endorses adequate sleep
  • Exercise: Reports minimal exercise
  • Diet: Reports unbalanced diet, minimal vegetables.
  • Caffeine: Denies caffeine use.

 

ROS:

  • General: Denies fever, fatigue, chills, night sweats, weight loss/gain, changes in appetite.
  • Skin, hair, nails: Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
  • HEENT: Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, epistaxis, discharge, congestion, sore throat, bleeding gums.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Pulmonary: Denies cough, dyspnea, wheezing, cyanosis, hemoptysis.
  • Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, palpitations.
  • Gastrointestinal: Admits to abdominal pain. Denies nausea, vomiting, diarrhea, constipation.
  • Genitourinary: Admits to vaginal bleeding. Denies urinary urgency, urinary frequency, dysuria, abnormal vaginal discharge.
  • Musculoskeletal: Denies muscle pain, joint pain, arthritis, or swelling.
  • Nervous system: Denies headache, loss of strength, change in cognition/mental status/memory.
  • Peripheral vascular: Denies intermittent claudication, coldness of extremities, peripheral edema.
  • Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
  • Endocrine: Denies polydipsia, heat or cold intolerance, excessive sweating.
  • Psychiatric: Denies depression or anxiety.

 

Physical Exam:

Vitals:

  • Weight: 178 lb Height: 59 inches       BMI: 35.9 kg/m2
  • BP: 127/67, right arm sitting
  • RR: 16, unlabored
  • HR: 71, regular
  • Temp: 99.5 F oral
  • SpO2: 100% room air

General: 24-year-old obese female who appears stated age. A/O x 3 and appears in pain.

HEENT: Normocephalic & atraumatic; PERRL; EOM intact; nares patent B/L; Pharynx non-erythematous. No exudates present.

Neck: Trachea midline. Neck supple and non-tender. No lymphadenopathy present.

Heart: Regular rate and rhythm. S1 & S2 distinct with no murmurs or gallops.

Lungs: Clear to auscultation B/L. No adventitious sounds noted.

Abdominal: Abdomen symmetric and non-distended, with no scars. Normoactive bowel sounds in all 4 quadrants. Suprapubic tenderness, no guarding or rebound.

Pelvic: Minimal dried blood visualized in vaginal vault. No frank bleeding from os. No CMT or adnexal tenderness. No abnormal discharge. Cervical os appears closed. [Exam chaperoned by _____]

Musculoskeletal: FROM, no cyanosis, no ecchymosis or open wounds. + Tenderness to para-spinal muscles. No midline pain. No peripheral edema.

 

Labs:

CBC –

 

 

 

 

 

 

 

 

 

BMP –

 

 

 

 

 

 

Hepatic –

 

 

 

 

UA –

 

 

 

 

 

 

 

 

 

 

 

HCG quant –

 

 

 

Imaging:

Transvaginal ultrasound –

  • Single live intrauterine pregnancy, with estimated fetal age 12 weeks, 0 days (crown-rump length 51.9 mm)
  • Fetal HR 136-138 bpm
  • Anterior placenta
  • Minimal fluid within the cervical canal
  • Left ovary not identified. Normal vascular flow to right ovary.

 

Assessment/Plan:

24 y/o G3P2 female presenting to ED with positive pregnancy test 1 week ago c/o vaginal bleeding and abdominal pain x 3 days s/p mechanical fall on buttock. LMP 8/30. Transvaginal ultrasound reveals a single intrauterine pregnancy with estimated fetal age 12 weeks, fetal HR positive @ 136-138 bpm.

 

#Vaginal bleeding / abd pain

  • Labs: type & screen, PT/PTT, UA/UC, POC urine pregnancy, quant HCG, CBC, BMP, hepatic
  • Transvaginal ultrasound
  • Analgesia: acetaminophen 325 mg now

 

Dispo: Discharge home

  • Prenatal vitamins QD sent to pharmacy
  • OB referral given to establish care
  • Return precautions given: return if worsening or intractable pain, intractable nausea or vomiting, fever/chills, worsening vaginal bleeding