IDENTIFICATION: September 10, 2019
LL, F, African America, 25 years old, single, 410 Coast Place, Queens, NY 12564, Catholic.

INFORMANT: Patient herself is a reliable historian.

REFERRAL SOURCE: Self

CHIEF COMPLAINT: ‘Vaginal Bleeding & Lower Abdominal Pain’ x 5 days

PRESENT ILLNESS: 25-year-old female P0010 with LMP 7/15/19 presents 5 days s/p dilatation and curettage complaining of vaginal bleeding and sharp, constant left lower quadrant abdominal pain radiating to her lower back, no trauma, injury or fall. Patient reports intermittent bleeding following the procedure until yesterday when it became constant, requiring the use of 3 pads / day and notes the abdominal pain worsened overnight, to 10/10 pain, with minimal relief from Tylenol & Ibuprofen, prompting her visit to the ED this morning.  Denies nausea, vomiting, chills, fever, constipation, diarrhea, headache, dizziness, palpitations, dyspnea, chest pain, dysuria, urinary frequency or urgency or vaginal discharge.

Of note, patient 7w3d at the time of D&C and received one course of antibiotics following the procedure.  Patient reports ultrasound done prior to procedure confirmed IUP. Patient notes she called the on-call number for the clinic where she had the procedure done but was unable to connect with the team prior to arrival in the ED. 

OB History: G1, P0010, 1 elective termination of pregnancy.
Gyn History: Regular menses.  Reports 6cm x 5cm fibroid noted following sonogram done prior to procedure.  Denies history of cancer (gynecologic, breast or colon), fibroids, ovarian cysts, pelvic cysts, chronic pelvic pain, STIs. Last pap smear done August 2019 with normal results.

PAST MEDICAL HISTORY

• None

PAST SURGICAL HISTORY

• D&C 9/5/19

MEDICATIONS

• None

ALLERGIES

• NKDA
• No food/environmental allergies

FAMILY HISTORY

• Noncontributory, no history of breast, cervical, ovarian, uterine or colon cancer.

SOCIAL HISTORY

• Reports social EtOH.  Denies smoking or illicit drug use.  Patient is single and lives with her family.

REVIEW OF SYSTEMS
General: Denies generalized weakness / fatigue, recent weight loss, change in appetite, fevers and night sweats.
Skin, hair and nails: Patient denies excessive dryness or sweating, moles/rashes or pruritus.
Head: Patient denies intermittent headaches, vertigo, light-headedness or head trauma.
Eyes: Patient denies visual disturbances, blurring, diplopia, fatigue with use of eyes, scotoma, halos, lacrimation, photophobia or pruritus. Last eye exam unknown. Patient does not wear glasses.
Ears: Patient denies deafness, pain, discharge, tinnitus.  Patient does not wear hearing aids.
Nose/Sinuses:  Patient denies discharge, epistaxis, obstruction.
Mouth and throat:  Patient denies jaw tightness, dry mouth, sore tongue, mouth ulcers, bleeding gums, sore throat or voice changes.
Neck:  Patient denies localized swelling/lumps or stiffness/decreased range of motion.
Pulmonary System:  Patient denies dyspnea on exertion (DOE), dyspnea (SOB), cough, hemoptysis, cyanosis, orthopnea or paroxysmal nocturnal dyspnea (PND).
Cardiovascular System:  Patient denies HTN, chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur.
Gastrointestinal System:  Reports abdominal pain / discomfort. Patient denies diarrhea, rectal bleeding / blood in stool, nausea, constipation, change in bowel habits, vomiting, changes in appetite, intolerance to specific foods, dysphagia, pyrosis, flatulence, eructations (belching, burping), jaundice or  hemorrhoids.
Genitourinary System:  Reports vaginal bleeding. Patient denies dysuria, urinary urgency, discoloration or urine, frequency, nocturia, oliguria, polyuria, incontinence, awakening at night to urinate or flank pain.

1. Sexual History 

• • Patient is single and sexually active with men. 
  • Reports regular menses.

Nervous System: Patient denies headache, seizures, loss of consciousness, sensory disturbances, numbness, parethesias, dysesthesias, hyperesthesias, ataxia, loss of strength, change in cognition / mental status.
Musculoskeletal System: Reports lower back pain.  Denies swelling and bruising or any history of arthritis.
Peripheral Vascular System: Patient denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins or color change.
Hematologic System:  Patient denies history of PE, anemia, easy bruising or bleeding, lymph node enlargement.  Patient denies blood transfusions.
Endocrine System:  Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating.
Psychiatric: Patient denies anxiety, depression/sadness, feelings of helplessness, feelings of hopelessness, lack of interest in usual activities, suicidal ideation, anxiety, obsessive / compulsive disorder.  

GENERAL SURVEY: 25-year-old female A/O x3, appears to be of stated age, well nourished, in no acute distress and cooperating well in the ED.

VITALS
BP: 100/65 mmHg
R: 19 BPM
P: 96 BPM
SpO2: 98% on RA
Temperature: 36.9 C

PHYSICAL EXAM
SKIN:  Warm & dry, good turgor.  Nonicteric, no lesions, no tattoos.
HAIR: Good quantity and equal distribution.
NAILS: No clubbing, capillary refill <2 seconds throughout.
HEAD: NC/AT nontender to palpation throughout.
EYES: No conjunctival injection, bilaterally, cornea clear. EOMI bilaterally, no discharge.
EARS: Symmetrical & normal size. No evidence of lesions, masses, trauma on external ears. No discharge or foreign bodies in external auditory canals AU. TMs pearly white, intact with light reflex in normal position 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 or perforation. No evidence of foreign body.
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. Intact with no masses, lesions or scars.
TONGUE: Pink, well papillated, no masses, lesions or deviations noted. Oropharynx well hydrated, no evidence of injection, exudates, masses, lesions, foreign bodies. Tonsils present with no evidence of injection or exudates, tonsilith noted on left tonsil. Uvula pink, no edema, lesions.
NECK: Supple, no lymphadenopathy.
LUNGS: Clear to auscultation bilaterally. Chest expansion symmetrical. No wheezing, rhonci, crackles, rales noted.
HEART: RRR. S1 & S2 normal. No murmurs or gallops noted.  Carotid pulses 2+ bilaterally.
ABDOMEN: Soft, non-tender, BS active in all four quadrants. Mild suprapubic tenderness.  No rebound, guarding or peritoneal signs. No CVA tenderness.
GENITOURINARY: Normal external female genitalia, no erythema, inflammation, ulcerations, lesions or discharge noted.  No active vaginal bleeding. Vaginal mucosa normal. Sterile Speculum Exam:  small blood clot 1 x 1cm mixed with mucus in posterior fornix, no frank bleeding.  No lesions or abnormal discharge seen. Bimanual exam: cervical OS closed.  Uterus normal sized, anteverted and non-tender.  Adnexa without masses or tenderness. Bedside Transvaginal Ultrasound: Uterus empty and normal in size.  No remaining products of conception.
VASCULAR: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No clubbing or cyanosis noted bilaterally (no C/C B/L).
NEURO: Alert and oriented to person, place and time. Memory and attention intact. No gross deficits.
MUSCULOSKELETAL: no erythema, ecchymosis, edema or acute abnormality noted, FROM, 5/5 strength with sensation intact.  

DIAGNOSTICS:
LABS –
CBC: 

• WBC: 11.05 (high)
• RBC: 3.73 (low)
• Hgb: 12.5
• HCT: 37.2
• Platelets: 302

CMP:

• BUN: 5 (low)
• Sodium: 138
• Potassium: 4.2
• Chloride: 102
• CO2: 21
• Glucose: 82
• Creatinine: 0.57
• Calcium: 9.4

HCG Quant:

• 4,442.0 (down from 16,981 on 8/23/19)

Urinalysis: negative for infection

IMAGING –
TRANSVAGINAL ULTRASOUND: done bedside, see physical exam.

ASSESSMENT:
25-year-old female, P0010 with LMP 7/15/19, presents 5 days s/p dilatation and curettage complaining of lower abdominal pain and abnormal vaginal bleeding expected side effects following dilatation and curettage.

PLAN:

• Suprapubic Pain / Abnormal Vaginal Bleeding:

1. 1. Return to All Women’s Kew Gardens clinic on given date (in one week) for post-D&C follow up.
   2. Pain Management: continue Motrin 600mg q 6h to control pain.
   3. Patient instructed to return to the ED (or Kew Gardens clinic) if worsening or concerning symptoms develop including signs of fever, worsening abdominal pain, increased bleeding, dizziness, vomiting, chills or dyspnea.
      

Differential Diagnosis

1. Retained products of conception / incomplete abortion
2. Dysfunctional Uterine Bleeding
3. Dysmenorrhea
4. Septic Shock
5. Vulvovaginitis