H&P #3

IDENTIFYING DATA:

  • Date & Time: 5/2/23 2:00 pm
  • Full Name: A. D.
  • Address: ———
  • DOB: –/–/2002
  • Location: Queens Hospital Center
  • Source of information: self
  • Reliability: reliable

 

CHIEF COMPLAINT: vaginal bleeding x 2 days

HISTORY OF PRESENT ILLNESS:

20 y/o G2P0010 with PMHx spontaneous missed abortion in 2022 with current gestational age of 9w 4d presents estimated by LMP 2/24/23 presents to the ED c/o vaginal bleeding x 2 days. Patient states bleeding began yesterday as light spotting that required a panty liner, but bleeding worsened in the middle of the night. Patient reports 12 hours of heavy flow, maroon in color and required changing of pad q6H, fully soaked. States bleeding has currently stopped. Patient established OB care at QHC w/ initial visit 1 week ago with + IUP visualized and + fetal heart tones. Patient reports she has been compliant with PNV and Fe. Patient denies trauma to abdominal or vaginal area. Reports last sexual encounter was 4 days ago. Denies fever, chills, abdominal pain, dysuria, nausea, vomiting, vaginal discharge, leakage of fluid.

Patient states this is a desired pregnancy.

EDD: 12/1/2023 calculated by LMP

 

Differential Diagnosis:

  • Spontaneous abortion
    • Missed
    • Inevitable
    • Complete
    • Incomplete
    • Threatened
  • Trauma / Cervical irritation

 

MEDICAL HISTORY:

Medications:

  • Ferrous sulfate (Feratab) 325 (65FE) mg 1 tablet PO BID
  • Prenatal multivitamin (prenatal plus) 27-1 mg tablet 1 tablet PO QD
  • Denies OTC or herbal supplement use

Medical History:

  • Spontaneous missed abortion – 2022

 Immunization Hx:

  • Up to date
  • Gardasil – completed series
  • Influenza vaccine received 1/2023
  • COVID series completed 2021 (2 doses)

Surgical History:

  • Dilation and curettage 5/20/2022
    • Location: QHC
    • Surgeon: George Seaman, MD
    • No complications

 Allergies:

  • No known drug allergies
  • No known food allergies
  • No known environmental allergies

Family History:

  • Mother: alive & well, no significant PMHx
  • Father: alive & well, no significant PMHx
  • Patient reports no known hx of cancer or heard disease in family.

 Social History:

  • Nonsmoker
  • Denies alcohol use. Denies illicit drug use.
  • Occupation: Unemployed
  • Caffeine: Denies caffeine use.
  • Marital history: Married
  • Home situation: Living in third floor walkup apartment with husband.
  • Diet: Patient reports balanced diet
  • Exercise: Patient reports minimal daily exercise

 OB History:

  • G2P0010
    • Pregnancy outcomes:
      • #1: Spontaneous missed abortion – D&C @ 10w 4d
      • #2: Current

GYN/Sexual history:

  • Menarche: age 15
  • Menstrual cycle: Regular, every 30 days, 5 days in duration
  • LMP: 2/24/23
  • Sexually active with 1 male partner.
  • Contraception: Patient denies contraceptive use, states she has been trying to conceive for 3 months.
  • No known history of STDs.

 

ROS:

  • General: Denies recent weight loss, fever, chills.
  • Skin, hair, nails: Denies rashes, changes in hair distribution or texture.
  • Head: Denies headaches, vertigo or head trauma.
  • Eyes: Denies blurred vision, photophobia, or changes in vision.
  • Ears: Denies pain, discharge, or changes in hearing.
  • Nose/sinuses: Denies discharge, congestion, and epistaxis.
  • Mouth/throat: Denies bleeding gums, sore throat, voice changes.
  • Neck: Denies localized swelling/lumps or stiffness/decreased range of motion.
  • Breast: Denies nipple discharge, masses or pain.
  • Pulmonary system: Denies dyspnea, cough, wheezing, and dyspnea on exertion.
  • Cardiovascular system: Denies history of HTN, chest pain, syncope, palpitations.
  • Gastrointestinal system: Has regular bowel movements 4-5x per week. Denies constipation, diarrhea, bloody stool, nausea, vomiting, and hemorrhoids.
  • Genitourinary system: Denies dysuria, incontinence, urinary frequency.
  • Menstrual/Obstetrical – See HPI.
  • Nervous: Denies loss of strength, seizures, loss of consciousness.
  • Musculoskeletal system: Denies muscle/joint pain, deformity or swelling, redness or arthritis.
  • Peripheral vascular system: Denies intermittent claudication, peripheral edema.
  • Hematological system: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.
  • Endocrine system: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.
  • Psychiatric: Denies depression, anxiety, hx of seeing mental health professional.

 

PHYSCIAL:

General: AAO x 3. Appears stated age. Appears in no acute distress.

Vitals:

  • BP: 107/72
  • Pulse: 68, regular
  • RR: 18 breaths/min
  • Temp: 98.2 oral
  • Wt: 120 lb
  • Ht: 63 in
  • BMI: 21.3 kg/m2
  • LMP: 2/24/23

Skin/Hair/Nails: Skin nonicteric, no lesions noted, no tattoos. Hair average quantity and distribution.

HEENT: Head normocephalic, atraumatic. Good dentition, no obvious dental caries noted. No gingival hyperplasia or erythema noted. Pharynx non-erythematous.

Thyroid: Non-tender; no palpable masses or nodules; no thyromegaly.

Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Chest: Symmetrical, no deformities, no trauma. Respirations unlabored, no use of accessory muscles noted.

Lungs: Clear to auscultation bilaterally, no adventitious sounds noted. Chest expansion and diaphragmatic excursion symmetrical. 

Abdomen: Abdomen symmetric, no striae noted. Bowel sounds normoactive in all four quadrants. Non-tender to palpation, no guarding or rebound noted. No CVA tenderness appreciated.

Breast: Deferred.

Female Genitalia: External genitalia without erythema or lesions. Cervix closed. Blood visualized in vaginal canal. No fetal tissue or active bleeding visualized. Uterus anterior, non-tender. No cervical motion tenderness or adnexal tenderness/masses noted.

Rectal: Deferred.

Extremities: No cyanosis, edema or deformities. No tenderness to calves. FROM.

Neurologic: Strength and sensation intact.

 

WORKUP:

  • Bedside sono: +IUP +Fetal heart tones

 

ASSESSMENT:

20 y/o G2P0010 9w 4d dated by LMP presents to ED c/o vaginal bleeding x 2 days. On exam, cervical os is closed. Sono shows + IUP and + Fetal heart tones. Symptoms and signs consistent with threatened abortion.

 

PLAN:

#Threatened abortion

  • Labs: CBC, Type & screen, beta-hcg, UA
  • Continue prenatal vitamins/iron
  • Repeat ultrasound and beta-hcg 1 week
  • Patient counseled about the risk of miscarriage
  • Consider bed rest
    • Patient advised to avoid vigorous activity, heavy lifting, and sexual intercourse
  • Patient counseled about the risk of miscarriage
  • Advised to return to ER if worsening abdominal cramping, increase in vaginal bleeding, passage of products of conception, fever, chills, nausea, vomiting