Chief Complaint: “belly pain and bleeding” x 1 month

Subjective:

29 y/o female without significant PMHx presents with lower abdominal pain and vaginal bleeding x 1 month. The pain is intermittent, non-radiating, and mostly located below the umbilicus, with a pain scale of 8/10. Pt never experience this before and OTC Ibuprofen doesn’t help to relieve her pain. She also has to change her pads 4-5 times per day. She also went to NYU urgent care and had sonogram done for pelvic, abdomen, and kidney. Denies being sexually active, use of OCP, N/V/D, period irregularity, dysmenorrhea, and previous history of STDs.

Objectives:

Allergies: none

Current Medication: none

Vitals:

BP 119/87, sitting position, left arm

HR 88bpm, RRR

RR 16 breaths per minute, regular

O2 98%, room air

T 98.7 oral

Ht 5ft 1.75 in    Wt 164 lbs     BMI 30.24

Physical exam:

General: in mild distress, good hygiene, A/O x 3

HEENT: Head: NC/AT. Neck: supple, no lymphadenopathy. Eyes: no redness, PERLLA. Nose: no deviation, no nasal discharge, no inflammation. Throat: tonsils are normal, no exudates or redness. Ears: normal tympanic membrane

CV: RRR, normal S1 S2, no murmurs, clicks, gallops.

Resp: clear to auscultation bilaterally, no adventitious sounds.

GI: BS present, uterine tenderness upon palpation

Extremities: no edema/swelling, pulses 2+ b/l

MSK: no swelling/deformity

Neuro: CN II-XII grossly intact

Imaging Studies:

Sonogram

Pelvic: multiple intramural uterine fibroid

Kidney: within normal limit

Abdomen: 1.4cm hyperechoic mass at right lobe

Assessment:

29 y/o healthy female presents with lower abdominal pain and prolonged vaginal bleeding x 1 month. History and sonogram most consistent with intramural uterine fibroid.

Differential Diagnosis:

Uterine Fibroid

Endometriosis/Adenomyosis

Irregular menstruation

Coagulation Disorder

Endometrial hyperplasia

Plan:

• Intramural uterine fibroid:

Order CBC, CMP, PT/PTT

Refer to GYN

• Abnormal findings on diagnostic imaging of liver:

Refer to MRI

• Obesity:

Diet and exercise counseling.