HP 3

Ling Yi Mei

Rotation #5

Identification:

Patient’s name: SD

Age: 23

Gender: F

Race: African American

Location: Brookdale ER, Brooklyn

Date and Time: 6/12/19

Informant: self, reliable

CC: “vaginal bleed” x 1 day

HPI:

23 y/o G1P0 female w/o PMHx at 6-week gestation presents with vaginal bleeding x 1 day. Pt reports bright red blood without clots and she has used 2 pads throughout the day. Bleeding is also accompanied with pelvic cramping, nausea, and 2 episodes of vomiting. Patient admits to her boyfriend being unfaithful and they have started an argument prior to her symptoms. She just found out her pregnancy recently by doing a home preg urine test, but had not yet have the chance to see an OB or have any pre-natal care. Pt denies any previous experience of abnormal vaginal bleeding, trauma, recent sexual intercourse, self-treatment, any alleviating or aggravating factors. Further denies fever, chills, SOB, chest pain, diarrhea/constipation, dysuria, back pain, abnormal vaginal discharge, or previous hx of STDs/PID.

Differential Diagnosis:

1. Threatened abortion: vaginal bleeding in less than 20-week gestation
2. Ectopic pregnancy: pelvic pain and vaginal bleeding in a pregnant woman

PMH:

None

Past Surgical History:

None

Medications:

None

Allergies:

None

NKDA

Family History:

Patient is an adopted child. Does not know her family history from her biological parents.

Social History:

Denies smoking cigarettes, alcohol, or use of illicit drug. Currently unemployed and lives with her boyfriend. She is sexually active with one partner, does not use contraception, and with man only.

ROS:

General: Patient denies recent weight loss or weight gain, generalized weakness, fatigue, fever, chill or night sweats. Positive: loss of appetite

Skin, Hair, Nails: Patient denies any changes of texture, excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus, or changes in hair condition

Head: Patient denies headache, vertigo, head trauma, or fracture

Eyes: Patient denies visual disturbance, lacrimation, photophobia, pruritus, or last eye exam

Ears: Patient denies deafness, pain, discharge, tinnitus

Nose/Sinuses: Patient denies discharge, epistaxis, or obstruction

Mouth and throat: Patient denies bleeding gums, sore tongue, sore throat, mouth ulcers or last dental exam

Neck: Patient denies localized swelling or lumps, stiffness or decreased range of motion

Breast: Patient denies lumps, nipple discharge, pain, or last mammogram

Pulmonary System: Patient denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea

Cardiovascular System: Patient denies chest pain, palpitations, edema, syncope, or known heart murmur

Gastrointestinal System: Patient denies, intolerance to specific foods, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool or stool guaiac test or colonoscopy. Positive: Nausea, vomiting.

Genitourinary System: Patient denies changes in frequency, nocturia, urgency, oliguria, polyuria, dysuria, change in color of urine, incontinence, awakening at night to urinate, or pain

Menstrual and Obstetrical: Patient last normal period is May 1st, the time of menarche is age 12, her menstrual cycle is 28 days with medium flow without clots. Patient denies postcoital bleeding, dyspareunia

Nervous System: Patient denies seizures, headache, loss of consciousness, sensory disturbances, numbness, paresthesia, dysesthesias, ataxia, loss of strength, change in cognition, mental status, memory, or weakness

Musculoskeletal System: Patient denies muscle or joint pain, deformity or swelling, redness, arthritis

Peripheral System: patient denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes

Hematological System: Patient denies anemia, easy bruising or bleeding, or lymph node enlargement

Endocrine System: Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance or goiter

Psychiatric: Patient denies depression, sadness, feeling of helplessness, hopelessness, lack of interest in usual activities, anxiety, obsessive or compulsive disorder, seen a mental health professional, or use medications

Physical Examination:

General: 23 y.o femaie is alert and cooperative. She is well dressed and doesn’t appear to be distressed. Neatly groomed, looks like her stated age of 23 years. Well developed. Currently she is emotionally unstable due to her boyfriend being unfaithful.

Vital Signs:

BP (seated): 120/70

HR: 80 bpm, regular

RR:  18, not labored

Temp: 97.7 F oral

O2 sat: 100% room air

Skin: Warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.

Hair: Average quantity and distribution

Nails: No clubbing, capillary refill <2 seconds throughout.

Head: Normocephalic, atraumatic

Eyes: Symmetrical OU; no exophthalmos or ptosis

Ears: Symmetrical and normal size. No lesions, masses, trauma on external ears.

Nose: Symmetrical with no masses, lesions, deformities, or trauma.

Lips: Pink, dry, no cyanosis or lesions

Mucosa: not performed

Palate: not performed

Teeth: not performed

Gingivae: not performed

Tongue: not performed

Oropharynx: not performed

Neck: No masses, lesions or scars. Trachea midline

Thyroid: not performed

Chest: Symmetrical, lat to AP diameter 2:1, no deformities, no trauma. Respirations unlabored.

Lungs: Clear to auscultation and percussion bilaterally. Chest expansion symmetrical. No wheezing, crackles, rales

Heart: S1, S2 without murmur, no gallops, S3 or S4.

Abdomen: Flat, symmetrical, no scars. Bowel sounds in all 4 quadrants. No bruits. Tympany to percussion throughout. Nontender to percussion or to light and deep palpation. No guarding, or rebound tenderness. No CVAT bilaterally

Anus/Rectal: not performed

Female genitalia: External – normal pubic hair pattern, no erythema, inflammation, ulcerations, lesions or discharge. Vaginal mucosa without inflammation, erythema or discharge. Cervix without lesions or discharge. No cervical motion tenderness. Uterus non-tender and of normal size, shape, and consistency. Adnexa without masses or tenderness. Cervical os is non-dilated, minimal bright red blood.

Peripheral vascular: not performed

Neurological:

Mental status: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted

Cranial nerve: not performed

Motor/Cerebellar: Full active and passive ROM of all extremities without rigidity or spasticity.

Sensory: not performed

Reflexes: not performed

Musculoskeletal System:

Upper extremities and lower extremities: Full range of motion of all upper and lower extremities bilaterally. No spinal deformities

Imaging and Labs:

Urine Preg: positive

Hcg quan: high

CBC: normal

BMP: normal, except anion gap with ketone is 17.7 (high)

PT/PTT: normal

Type and screen: A+

U/A: protein 30, trace ketone, and large blood. Everything unremarkable

Urine Microscopic: normal

Transvaginal ultrasound: gestational sac with an intrauterine pregnancy and good fetal movement and fetal heart beat. Minimal blood on the probe.

Assessment:

23 y/o G1P0 female at 6-week gestation presents with vaginal bleeding and pelvic cramping x 1 day. Cervical os is non-dilated. Transvaginal ultrasound reveals intrauterine pregnancy and fetal heart beat. Most consistent with threatened abortion.

Differential Diagnosis:

1. Threatened abortion: vaginal bleeding, pelvic cramp, less than 20 week gestation, cervical os closed, and no passage of fetal tissue
2. Inevitable abortion: less likely because the cervical os is non-dilated
3. Molar pregnancy: vaginal bleeding, nausea and vomiting during the 1^st Unlikely because the ultrasound reveals intrauterine pregnancy with good fetal heart rate.
4. Ectopic Pregnancy: unlikely because ultrasound shows intrauterine pregnancy
5. Ovarian cysts: due to lower abdominal pain. Unlikely with patient complaint of vaginal bleeding

Plan:

1. IV fluid, 0.9% sodium chloride IV bolus
2. Zofran 2mL IV injection
3. Best rest and f/u with OB clinic, may need to repeat ultrasound and hCG levels to determine a viable pregnancy
4. Physical activity precautions and abstinence from sexual intercourse
5. Return to ED if severe bleeding and abdominal pain, lightheadedness or dizziness, fever

 

Patient Education:

Threatened abortion is when vaginal bleeding occurs in less than 20 weeks of gestation without cervical dilation. We will do lab works on you, as well as a transvaginal ultrasound to locate the pregnancy and determine if the fetus is viable. Your transvaginal ultrasound is showing intrauterine pregnancy and good fetal heart beat, which is definitely a good sign. What we can do in the ED is to give you some medication and fluid for nausea and vomiting. Patients with a threatened abortion are usually managed expectantly until their symptoms resolve. A miscarriage cannot be avoided or prevented. It is important to follow up with the OB clinic not only for pre-natal care, but also for repeat pelvic ultrasound and beta-hCG levels to determine a viable pregnancy. Also, please return to the ED if there is heavy bleeding or if your are experiencing lightheadedness or dizziness, increased pain, or fever.