CHIEF COMPLAINT: Ovulation pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who states that she has had chronic pelvic pain in the past. Her pain seems to be during the same time each month. She has had a history of uterine ablation in the past. She had increased pelvic pain in the left lower quadrant this morning. She used a heating pad without any improvement in her symptoms. Now, her pain is present in the lower quadrants bilaterally and has progressively become worse. It is a throbbing sensation, 10/10 in intensity, and is constant. She has not seen GYN for this. The patient states that tonight she noticed a gush of blood when she went to the bathroom. She is unsure of her last menstrual period. It was before her uterine ablation.
PAST MEDICAL HISTORY: Uterine ablation, COPD, depression.
SOCIAL HISTORY: The patient denies tobacco use, occasionally drinks alcohol.
ALLERGIES: NKDA.
PHYSICAL EXAMINATION:
GENERAL: A well-developed (XX)-year-old Hispanic female.
VITAL SIGNS: BP 110/72, temperature 99.6, pulse 100, respirations 18.
HEENT: Moist mucous membranes.
HEART: Regular rate and rhythm, S1, S2.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft. Positive bowel sounds. Tender with palpation in the lower quadrants bilaterally. No rebound, no guarding, no masses.
PELVIC: Normal external genitalia. Cervix is closed. No active bleeding. There is a brownish discharge seen. She is diffusely tender with palpation, including the cervix and bilateral adnexa. No masses noted.
EXTREMITIES: No clubbing, cyanosis or edema.
LABORATORY DATA: CBC normal. Pregnancy test is negative. Urinalysis shows 5-10 rbc’s, 3-5 wbc’s. Otherwise, negative. PTT is 24.4 with an INR of 2.2.
EMERGENCY DEPARTMENT COURSE: The patient was seen and examined. She underwent workup. She was given morphine and Phenergan for her discomfort. Upon re-examination, she was still having pain. She stated that she was on Coumadin and wanted to make sure that she was not overly anticoagulated. Therefore, a PT was added to her blood work. She was given another dose of morphine. Upon re-examination, again, she was still having pain. Her old charts were reviewed. She was given one dose of Demerol, and she was discharged in good condition.
MEDICAL DECISION MAKING: A (XX)-year-old Hispanic female with pelvic pain. The patient was discharged home. Motrin over-the-counter 3 times a day. Ultram 50 mg. She is to follow up with GYN. Return for worsening symptoms.
DIAGNOSIS: Acute exacerbation of chronic pelvic pain, of uncertain etiology.
DISPOSITION: Home.
*************************************************************************************************
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who presents to the emergency department with right lower quadrant abdominal pain that has been present for last 3 days. She thought it was gas. It is intermittent, but it has been fairly constant today. She has had no nausea or vomiting. She has been eating well. She has had pressure with urination, no urinary frequency or hematuria. No exacerbating or relieving factors. It is sharp and a pressure-like sensation. No vaginal discharge. No new partners. No fever or chills. She has had C-sections x2.
PAST MEDICAL HISTORY: C-section x2, appendectomy, ovarian cyst, D&C, asthma, lysis of adhesions.
SOCIAL HISTORY: Denies tobacco use.
ALLERGIES: None.
PHYSICAL EXAMINATION:
GENERAL: This is a well-developed (XX)-year-old, in no distress.
VITAL SIGNS: BP 118/72, temperature 98.4, pulse 98, respirations 18 and O2 sat 98% on room air.
HEENT: Moist mucous membranes.
HEART: Regular rate and rhythm. S1, S2.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, positive bowel sounds. Tender suprapubically and in the right lower quadrant. No rebound, no masses.
GENITOURINARY: Normal external genitalia. Cervix is closed. No discharge, no cervical motion tenderness. Uterus is slightly enlarged. She is tender over the uterus and right adnexum. No masses.
EXTREMITIES: No clubbing, cyanosis or edema.
LABORATORY DATA: Pregnancy test is negative. CBC is normal. Urinalysis: Dip is negative for leukocytes. There is a trace of blood, trace of ketones.
EMERGENCY DEPARTMENT COURSE: The patient was seen and examined. She underwent workup. She was given 2 Percocet for her pain. She was re-examined. Her abdomen has remained soft. She was discharged in good condition.
MEDICAL DECISION MAKING: The patient is a (XX)-year-old female with pelvic pain.
PLAN:
1. We will discharge her to home.
2. Lortab, number 12 prescribed.
3. She is to follow up with her PCP.
4. Motrin over-the-counter 3 times a day.
5. Return for worsening symptoms.
DIAGNOSIS: Acute pelvic pain, of uncertain etiology.
DISPOSITION: Home.
