Identification:

• Name: S.M
• Sex: F
• Race: Hispanic
• Nationality:
• Age: 25
• Marital Status: Not Married
• Address:
• Religion:

Informant:

• Source of hx: Self
• Competency: Competent

 

Referral Source:

CC:  “ I am bleeding a lot from my vagina” X1 day

HPI:

25 y/o Female G1P0, LMP in “late September”, presents to the ER for abnormal vaginal bleeding that started x15 hours ago. Patient states that she is sexually active with her boyfriend and her menses are normally irregular. She took a pregnancy test last week at home, which confirmed she was pregnant. She did not seek prenatal treatment when she found out she was pregnant. This morning at 2am, patient started to feel right sided pelvic pain (8/10), which awoke her from her sleep, and soon after she vomited food contents. She also started to experience mild vaginal bleeding at this point, but did not give much thought to it. The pain slowly subsided, and she was able to fall back asleep, but was awaken by her pain at 10 am again, where she experienced another episode of vomiting and more vaginal bleeding. Since that episode patient states the pain is constant and has moments of intermittent severity, mainly located to the right pelvic area. Patient states that she has changed her pad 3 times since the bleeding started. She is also experiencing anorexia, stating that she has not eating anything since last night, nor does she have an appetite at the moment. She denies current nausea, eating anything out of the ordinary, any breast tenderness/ pain, having a history of STI’s, clotting of blood, multiple sex partners, fever, pain around the belly button area, taking any medication for the pain, dyspareunia and vaginal or abdominal trauma.  Patient is unsure if she wants to keep the pregnancy.

OB/GYN Hx: G1P0, cannot recall if/when Pap Smear was done. Has never been tested for G/C.

• Ectopic Pregnancy- one sided pelvic pain with vaginal bleeding, and a positive home pregnancy test (positive in the ER as well).
• Appendicitis- Right sided abdominal pain, with nausea, vomiting, and loss of appetite.
• Ovarian Torsion- One sided pelvic pain, described it at constant with intermittent severity ( wax and wane pain)
• Ovarian Cyst- Unilateral RLQ pain with abnormal uterine bleeding. However, denies dyspareunia.
• Gestational trophoblastic disease – vaginal bleeding (however, unlikely because bleeding is painful)
• Spontaneous abortion (threatened)- Bloody vaginal discharge with positive HCG
• Sub chorionic hemorrhage- vaginal bleeding with pelvic pain, and possible cramping

Pmhx:

• None

 

Past surgical hx:

• None

Medications:

• None

Allergies:

• No known food, environmental or drug allergies.

Family hx:

• Mom- HTN
• Dad-Alive and Healthy
• Siblings- Alive and Healthy
• Children- None

Social Hx:

• Denies using drugs, tobacco, alcohol use, recent travel.

General:

• Admits to N/V and loss of appetite
• Denies fever, chills, fatigue, loss or gain of weight, diaphoresis and night sweats.

Skin, hair and nails:

• Denies change in texture to skin, hair and nails, excessive dryness, discolorations, pigmentations, sweating, moles/rashes, pruritis, and change in hair distribution.

Eyes:

• Denies visual disturbances, lacrimation, photophobia, itching, corrective lenses, blurriness, and discharge. Denies wearing glasses.

HENNT:

• Denies headaches, vertigo, head trauma
• Denies hearing loss, tinnitus, pain, discharge, wearing hearing aids
• Denies epistaxis, discharge, obstruction, rhinorrhea, stuffiness, sneezing, allergies
• Denies swelling/lumps, stiffness, or decreased ROM
• Denies sore throat, neck pain, hoarseness, bleeding in mouth/throat, sore tongue, mouth ulcers, voice changes or wearing dentures.

Breast:

• Denies lumps, nipple discharge, pain.

Pulmonary:

• Denies cough, wheezing, SOB, pain on inspiration, hemoptysis, orthopnea, cyanosis, PND, clubbing, or any history of asthma.

Cardiovascular:

• Denies CP, HTN, edema, palpitations, irregular heartbeats, syncope, claudication, murmurs, and orthopnea.

 

Gastrointestinal:

• Is experiencing nausea, episodes of vomiting, and decrease in appetite.
• Denies indigestion, intolerance of foods, diarrhea, jaundice, hemorrhoids, constipation any change in BM, dysphagia, pyrosis, flatulence, blenching or burping, rectal bleeding.

Genitourinary:

• Admits to abnormal vaginal bleeding
• Denies frequency, nocturia, urgency, dysuria, oliguria, lesions, discharge, hematuria, pyuria, dyspareunia, any flank pain.

Menstrual and Obstetrical:

• LMP: “late September”
• Menarche: 12
• Possibly actively menstruating, menses cycle varies anywhere from 3 weeks to 4 months.
• Denies postcoital bleeding, vaginal discharge, dyspareunia.

Nervous System:

• Denies seizures, headache, LOC, loss of strength, change in cognition, mental status, memory, ataxia, sensory disturbances, syncope, slurring of speech, focal weakness, neck stiffness, any decrease in sensation, and tingling.

MSK:

• Denies joint/muscle pain, deformity, swelling, redness, arthritis.

Peripheral Vascular System:

• Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, color change.

Hematologic System:

• Denies new or known bruising, bleeding, petechiae, purpura, blood transfusions, lymph node enlargement, hx of DVT/PE and anemia

Endocrine:

• Denies polyphagia, polyuria, polydipsia, intolerance to heat/cold, goiter, excessive sweating or hirsutism.

Psychiatric:

• Denies depression/sadness, suicidal ideation, anxiety, seeing a mental health specialist, memory deficits, OCD, and taking medication for mental illness.

 

Physical

General:

• Thin female, well nourished, in no acute distressed. Acceptable hygiene appears age stated. Is alert and cooperative

Vitals:

• BP: R
  1. Seated 132/89
• R: 17 breaths/min, unlabored
• P: 97 beats/min, regular
• T: 9 degrees F (oral)
• O2 Sat: 96% Room air
• Height 4 feet 11 inches Weight 125 lbs.    BMI: 25.2

Skin:

• Warm and moist, good turgor, nonicteric, no lesions, scars, or tattoos.

Head:

• No scars, bumps, trauma, tenderness to palpation, normocephalic, atraumatic

Hair:

• Average quantity and distribution

Nails:

• No clubbing, cap refill <2 seconds throughout.

Eyes:

• symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white, no icterus; 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.

Ears:

• Symmetrical and normal size. No evidence of lesions/masses / trauma on external ears.  No discharge / foreign bodies in external auditory canals AU.   TM’s pearly white / intact with light reflex in normal position AU.  Auditory acuity intact to whispered voice AU.

 

Nose:

• Symmetrical / no obvious masses / lesions / deformities / trauma / discharge. Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy.  Septum midline without lesions / deformities / injection / perforation.   No evidence of foreign bodies.

Sinuses:

• Non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.

Lips:

• Pink, moist; no evidence of cyanosis or lesions.

Mucosa:            

• Pink; well hydrated. No masses; lesions noted. No evidence of leukoplakia.

Palate:

• Pink; well hydrated.   Palate intact with no lesions; masses; scars.

Teeth:

• Decent dentition / no obvious dental caries noted.

Gingivae:

• Pink; moist. No evidence of hyperplasia; masses; lesions; erythema or discharge.

Tongue:

• Pink; well papillated; no masses, lesions or deviation noted.

Oropharynx:

• Well hydrated; no evidence of injection; exudate; masses; lesions; foreign bodies. Tonsils absent, no hx of removal.  Uvula pink, no edema, lesions

Neck:

• Good ROM. Trachea midline. No masses; lesions; scars; pulsations noted.   Supple; non-tender to palpation. No stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no palpable adenopathy noted.

Thyroid:

• Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Chest:

• Symmetrical, no deformities, no evidence trauma. Respirations unlabored / no paradoxical respirations or use of accessory muscles noted.  Lat to AP diameter 2:1.   Non-tender to palpation.

Lungs:

• Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical.   Tactile fremitus intact throughout.  No adventitious sounds. No rales, Rochi, or wheezing heard.

Heart:  

• Carotid pulses are 2+ bilaterally without bruits. RRR; S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.

Abdomen:

• Flat / 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. Tender to deep palpation of the right lower quadrant. Negative Rovsing, Psoas and Obturator Sign.
• No evidence of hepatomegaly or splenomegaly. No masses noted.   No evidence of guarding or rebound tenderness.   No CVAT noted bilaterally.

Pelvic exam:

• Normal appearing external female genitalia, normal vaginal epithelium, no abnormal discharge, minimal vaginal bleeding noted externally. Normal appearing cervix, minimal blood noted in the vaginal canal, cervical os closed. Bimanual: No CMT, mild right adnexal tenderness. No palpable adnexal masses.

Breast:

• Breasts: symmetric, no dimpling, no masses, nipples without discharge. No axillary nodes palpable.

Peripheral Vascular:

• The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally (no C/C/E B/L) No stasis changes or ulcerations noted.

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 Nerves:

• I – Intact no anosmia.
• II- VA 20/20 bilaterally. Visual fields by confrontation full.
• III-IV-VI- PERRL, EOM intact without nystagmus.
• V- Facial sensation intact, strength good. Corneal reflex not tested.
• VII- Facial movements symmetrical and without weakness.
• VIII- Hearing grossly intact to whispered voice bilaterally.
• IX-X-XII- Swallowing and gag reflex intact. Uvula elevates midline. Tongue movement intact.
• XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscles strong.

 

Motor/Cerebellar:

• Full active/passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone throughout. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally (5/5 throughout). No Pronator Drift. Gait normal with no ataxia. Tandem walking and hopping show balance intact. Coordination by RAM and point to point intact bilaterally. Romberg negative.

Sensory:

• Intact to light touch, sharp/dull, vibratory, proprioception, point localization, extinction, stereognosis and graphesthesia testing bilaterally.

Meningeal Signs:

• No nuchal rigidity noted. Brudzinski sign negative. Kernig’s sign negative.

MSK LE:

• No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted FROM (Full Range of Motion) of all upper and lower extremities bilaterally. No evidence of spinal deformities.

MSK UE:

• No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted FROM (Full Range of Motion) of all upper and lower extremities bilaterally. No evidence of spinal deformities.

Abnormal Pertinent Labs:

• HCG Quant – 1,549
• CBC with differential:
  11. WBC: 11.6
• CMP : WNL
• UA:
  1. Ketones: 15
  2. Protein: Trace
  3. Blood: Large
  4. Bacteria: Moderate
  5. Squamous Epithelial Cells: Moderate (10-20)!
• Rh factor- Positive

Transvaginal Bedside US:

• Endometrium thickened (1.4 cm)
• No free fluid noted
• No adnexal masses noted
• Right ovary showed adequate blood flow

 

Assessment:

25 y/o Female G1P0, LMP in “late September”, presents to the ER for abnormal vaginal bleeding that started x15 hours ago accompanied by right sided, intermittent pelvic pain, two episodes of vomiting and nausea. PE revealed mild vaginal bleeding, with mild right sided adnexal tenderness. HCG quant 1,549. Bedside-US, did not show an intrauterine pregnancy. Cannot rule out Ectopic Pregnancy versus Spontaneous Abortion.

 

Plan:

• Pain and Vaginal Bleeding:
  1. Tylenol PRN
  2. F/u with GYN clinic 2 days for repeat HCG level
  3. Inform patient that she should return to the clinic if pelvic/ abdominal pain becomes severe or she starts to experience heavy vaginal bleeding, or if N/V gets worse.

Patient Education:

• It is very important that you follow up with the GYN appointment, whether you want to keep this pregnancy or not. Depending on the results of the HCG levels at the follow up and vaginal ultrasound, we will decide what is needed at that point for your safety.
• It is important that you use contraceptives, especially because you are not sure if you want a baby at this point in your life. There is a wide variety of options that you could discuss with your gynecologist to see which birth control is best for you and your partner. Condoms are the only form of contraceptives that protects against pregnancy and STI’s, so even if you are placed on birth control, it is important to use condoms to prevent the transmission of STIs.
• It is important that you follow up with your PCP and know whether you have been tested for STI’s or have gotten a PAP smear, which helps to see if you have cervical cancer, which is something that we screen for every 3 years after the age of 21.