Identifying Data:
Full Name: Ms. RR
Address: Floral Park, NY
Date of Birth: September 22nd, 1988
Date & Time: July 28th , 2020
Location: NYC Health + Hospitals/Woodhull
Religion: Catholic
Source of Information: Self
Source of Referral: Self
Mode of Transport: Self
Chief Complaint: “I have bloody discharge from my vagina” x 3 days.
HPI:
Ms. RR is a 32-year-old female pregnant patient G6P3023 LMP 06/01/2020 EGA 8w0d and EDD 03/08/2021 is here today due to complains of bloody discharge from the vagina. Patient and her partner are happy with the pregnancy although it was unplanned. Patient states that about 3 days ago she noted her underwear was wet while she was shopping and when she got home she checked and discovered there was little amount of bright red blood in her underwear. She didn’t think much of it and continued with her day. The next day she noted that the bleeding was the same with no other signs of distress. On the third day the bleeding got worse and had a darker red color, and she also started experiencing general lower abdominal pain. When asked to point specifically where the pain was she said it was all over her lower abdomen. She described the pain as dull, constant throughout the day and did not radiate anywhere else and rated the pain a 4/10. Pt stated that ibuprofen makes the pain better and the last ibuprofen she took was last night 200mg. Patient stated that she never experienced anything like this before and decided to come in today because the bleeding and pain were getting worse. Patient denies N/V, fever, chills, dysuria, fatigue, vision change, dyspareunia, blood in stool, loss of consciousness, shortness of breath or chest pain.
Past Medical History:
Present illnesses – Denies any present illnesses.
Past medical illnesses – Otitis Media when she was a child.
Past OB/GYN Hx: 2 abortions, both done via D&C. First one done in 2008 (EGA 10weeks) and the second one done in 2011 (EGA 8 weeks). All 3 of her children were born via spontaneous vaginal delivery with no complications.
Immunizations- Up to date.
Screening tests and results- pap smear last year-benign.
Past Surgical History:
D&C- 2008 and 2011 for unwanted pregnancies.
Medications:
Ibuprofen PO, 200mg once a day for abdominal pain, last dose taken last night.
Allergies:
Denies drug, environmental or food allergies.
Family History:
Denies family history of cardiovascular diseases, cancer, strokes.
Mother: alive and healthy
Father: alive and healthy
Social History:
Patient currently lives with her husband and her 3 children. She works as a secretary for a law firm and likes to exercise by running around her neighborhood.
Denies use of alcohol, illicit drug use and the use of tobacco.
Travel- Has not recently traveled anywhere.
Sexual Hx- Sexually active with her husband. No past history of STD’s, HIV, or any other sexually transmitted diseases.
Review of Systems:
General: denies loss of appetite, fever, recent weight loss or gain, generalized weakness/fatigue, or night sweats.
Head – Denies headaches or head trauma.
Eyes – Denies lacrimation, pruritis, visual disturbances, or photophobia. Last eye exam 2019 – does not know his visual acuity.
Breast – Denies lumps, nipple discharge, or pain.
Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system – Denies chest pain, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur
Gastrointestinal system – Bilateral lower abdominal pain that is dull, constant and does not radiate anywhere else. Has regular bowel movements daily. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
Genitourinary system – denies urinary frequency, urgency, nocturia, polyuria, oliguria, dysuria, incontinence, or flank pain.
Menstrual/Obstetrical – G6P3023. Menarche age 13. LMP 06/01/2020 EGA 8w0d and EDD 03/08/2021 and presents with vaginal bleeding that’s been going on for 3 days now.
Physical exam:
General: Pt is alert and oriented x3, well dressed, slight distress due to ongoing abdominal pain and responsive to verbal commands.
Vital Signs: BP: R L
Seated 122/85 130/90
R: 18/min unlabored P: 70, regular
T: 98.0 degrees F (oral) O2 Sat: 98% Room air
Height 5 feet and 7 inches Weight 160 lbs. BMI: 25.1
Eyes – symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white.
conjunctiva & cornea clear.
Visual acuity (uncorrected – 20/20 OS, 20/20 OD, 20/20 OU).
Visual fields full OU. PERRLA, EOMs full with no nystagmus
Thorax & Lungs:
Chest– symmetrical, no deformities, no evidence of trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP 2:1, non-tender to palpations.
Lungs– Clear to auscultation and percussion bilaterally. Chest expansions and diaphragmatic excursions symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.
Heart: No tenderness to palpation. JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR); S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.
Abdomen: No hernias noted. Slight tender on palpation on the suprapubic region, slight distended / symmetrical / no evidence of scars, striae, caput medusae or abnormal pulsations. BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Tympany to percussion throughout. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.
Breasts: normal appearance, symmetric, no dimpling, no masses, or nipples discharge. No axillary nodes palpable
Female genitalia: Cervix os appears 3-5cm dilated with heavy vaginal bleeding and partial passage of product of conception. External genitalia normal, no adnexal masses or tenderness and slight cervical motion tenderness. Bimanual exam was unable to perform. Pelvic ultrasound shows some of the products of conception were still present in the uterus. 4cm by 3cm product of conception still present in the uterus.
Assessment:
Ms. RR is a 32-year-old female patient G6P3023 LMP 06/01/2020 EGA 8w0d and EDD 03/08/2021 and no significant PMHx is here today for vaginal bleeding. Bleeding has been going on for 3 days and is also associated with B/L lower abdominal pain. On physical exam dilation of the cervical os was noted with heavy vaginal bleeding and partial passage of product of conception. Pelvic U/S was done next which showed 4cm by 3cm product of conception still present in the uterus.
Problem list:
1) 8 weeks of gestational pregnancy- LMP 06/01/2020 EGA 8w0d and EDD 03/08/2021.
2) Abnormal vaginal bleeding x 3 days. (Incomplete spontaneous abortion).
3) B/L lower abdominal dull and constant pain x 1 day.
Plan:
1) Since this is an incomplete spontaneous abortion and partial products of conception have already come out, with the use of speculum and ring forceps try to remove as much as you can in the vaginal canal.
2) After doing so, order pelvic/transvaginal US and beta hCG to see if there are any products of conception left in the uterus.
3) If US shows POC in the uterus, start patient on 500 mcg oral misoprostol.
4) Order Urine Analysis & Culture to rule out any possible infections.
5) Order CBC and Differential and Type and Screen to see if patient is anemic due to recent blood loss.
6) Test if patient is Rh-negative or positive and if patient is Rh-negative start her on Rhogram (Rho(D) immune globulin).
7) If 500 mcg of misoprostol is not working and there is still POC in the uterus, prep patient for D&C (dilation and curettage).
8) Continue patient of Ibuprofen 200mg if there is still abdominal pain.
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