RT9-Emergency medicine-H&P2

Jinjin Lin

 

Identification:

Patient’s name: Ms. C

DOB: 30 years old

Gender: female

Race: Hispanic

Location: Woodhull hospital emergency department, Brooklyn, NY

Date and Time: 11/26/2019, 9 am

Informant: self, reliable

CC: “my lower abdomen hurts” x 4 hours

HPI: A 30 years old female with no reported past medical history presents with left lower quadrant abdominal pain since 5 am this morning. The pain is described as cramping, intermittent with a severity 9/10, not radiating, associated with mild vaginal spotting and nausea. LMP Sep 2019. Reports a history of right salpingectomy for an ectopic pregnancy in 2010. Denies chest pain, SOB, fever, chills, dizziness, headache, palpitation, active bleeding or passing clots.

Differential Diagnosis:

• Ectopic pregnancy: unilateral lower abdominal pain, spotting, nausea, history of ectopic pregnancy
• Ovarian torsion: severe unilateral intermittent lower abdominal pain

PMH:

Patient denies any past medical history.

Past Surgical History:

Right salpingectomy – 2010

Medications:

Patent denies taking any medications or supplements.

Allergies:

Patient denies any drug, foods, or environment allergies.

Family History:

Father- 58, alive, well

Mother- 54, alive, DM2

Sister- 33, alive, well

Social History:

Ms. C lives with her husband and parents in Brooklyn NY. She works as a receptionist in the bank, usually eats home make foods. Her sleep quality is good, and she usually sleeps about 7 hours a day. Sexually active with her husband only, not using contraception, denies a history of STDs. Denies recent travel, nicotine use, alcohol consumptions, past or present illicit drug use.

ROS:

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

Skin, Hair, Nails: Patient denies any changes of texture, excessive dryness or sweating, discolorations, rashes

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

Eyes: Patient denies photophobia, visual disturbance, lacrimation, or pruritus

Ears: Patient denies deafness, pain, discharge, tinnitus

Nose/Sinuses: Patient denies discharge, or obstruction

Mouth and throat: Patient denies bleeding gums, sore tongue, sore throat

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

Breast: Patient denies lumps, nipple discharge, pain

Pulmonary System: Patient denies SOB, DOE, cough, wheezing

Cardiovascular System: Patient denies chest pain, palpitations, edema, syncope

Gastrointestinal System: Patient reports left lower abdominal pain, nausea, denies dysphagia, vomiting, jaundice, hemorrhoids, constipation, blood in stool

Genitourinary System: Patient denies nocturia, urgency, oliguria, polyuria, dysuria

Nervous System: Patient denies headache, loss of consciousness, sensory disturbances, numbness, paresthesia, loss of strength, mental status, memory, or weakness

Musculoskeletal System: Patient denies deformity or swelling, or redness

Peripheral System: patient denies intermittent claudication, varicose veins

Hematological System: Patient denies anemia

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

Psychiatric: Patient denies depression, or anxiety

Physical Examination:

General: 30 years old female is alert to person, place, and time, appears well-developed and well-nourished. Non-toxic appearance, not in acute distress

Vital Signs:

BP (seated): 134/71

HR: 74 BMP, regular

RR: 16, not labored

Temp: 97.1 F oral

O2 sat: 99% room air

Height: 5ft 3in weight: 143lb BMI: 25.3, normal

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, non-tender to palpation throughout

Eyes: PERRLA, EOMs full with no nystagmus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear. Visual fields full OU.  Fundoscopy – Red reflex intact OU

Ears: Symmetrical and normal size. No lesions, masses, trauma on external ears. No discharge. TM’s pearly white, cone of light intact

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

Throat: Pink, hydrated, no lesions, uvula light pink, no edema

Neck: Trachea midline. Supple nontender to palpation. No lymphadenopathy

Chest: Symmetrical, no deformities. Respirations unlabored. Nontender to palpation

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

Heart: RRR, S1, S2 without murmur, no gallops

Abdomen: Flat, symmetrical, no distension. Bowel sounds present in all 4 quadrants. Soft, mild tenderness over left lower quadrant, no rebound tenderness or guarding

Pelvic: unremarkable female genitalia, small amount of blood in vault, no cervical motion tenderness, OS closed. No adnexal tenderness

Peripheral vascular: No cyanosis or edema noted bilaterally

Neurological:

Mental status: Alert and oriented to person, place and time. Memory and attention intact. Thought coherent.

Cranial nerve:

I – not exanimated.

II- Visual fields full. Fundoscopic + red light reflex OS/OD.

III-IV-VI- PERRLA, EOM intact without nystagmus.

V- Facial sensation intact.

VII- Symmetric facial movements, no weakness.

VIII- Hearing grossly intact to whispered voice bilaterally.

IX-X-XII- Swallowing and gag reflex intact. Tongue movement intact.

XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscles strong.

Motor/Cerebellar: Full active and passive ROM of all extremities

Sensory: Intact to light touch, sharp/dull

Meningeal signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

Musculoskeletal System: No soft tissue swelling, erythema, ecchymosis. Nontender to palpation, no crepitus noted throughout. Full range of motion.

Labs:

POC urine pregnancy positive

HCG-Quant 5,387

CBC

WBC 10.6

RBC 3.99 (slightly low)

HGB 12.9

HCT 39.5

MCV 99.1

MCH 32.3

RDW 11.9

PLT 267

Neutrophil 71.7

Lymphocyte 21.6

Monocyte 6.0

Eosinophil 0.4

Basophil 0.3

BMP

BUN 9

Sodium 136

Potassium 4.2

Chloride 102

CO2 22 (slightly low)

Glucose 100

Creatinine 0.60 (low)

Calcium 9.6

Albumin 4.1

Total bilirubin <0.2

AST 14

ALT 12

Anion gap 12

Lipase 23

Urine analysis

PH 8.5

Color yellow

Appearance cloudy

Glucose negative

Bilirubin negative

Ketones negative

Specific gravity 1.016

Blood negative

Protein negative

Nitrite negative

Leukocyte esterase negative

White blood cell not applicable

Red blood cell not applicable

Type and screen

ABO O

Rh positive

Antibody screen negative

Imaging:

Transvaginal and transabdominal ultrasound:

1. There is no evidence of a viable intrauterine gestation
2. There is a complex structure adjacent to the left ovary, there is free fluids present in the pelvis, possibility of ectopic gestation

Differential Diagnosis:

• Ectopic pregnancy
• Ovarian cyst: lower abdominal pain associated with nausea; mass found next to left ovary
• Completed abortion: vaginal spotting with OS closed

Assessment: A 30 years old female, G2P0010, with no reported past medical history presents with cramping, intermittent left lower quadrant abdominal pain since this morning with a severity 9/10, not radiating, associated with mild vaginal spotting and nausea. LMP Sep 2019. Physical exam notable for mild left lower quadrant tenderness. UA, CBC, BMP negative, pregnancy test positive, and ultrasound shows no viable intrauterine gestation and complex structure adjacent to left ovary. Current findings most consistent with ectopic pregnancy.

Plan:

• Ectopic pregnancy
• GYN is consulted, the patient is hemodynamically stable
• Methotrexate 89mg IM now
• Follow up in GYN clinic on 11/29 and 12/2 to repeat HCG level and CBC

Patient education:

• Based on your presentations with severe pain on the left side only, nausea, and pregnancy test is positive, and the ultrasound says there is no living gestation in the uterine, but there is a mass-like structure near your left ovary, which is highly suggested this is an ectopic pregnancy. Ectopic pregnancy is a pregnancy when the fertilized egg attaches itself in a place another than inside the uterus. The biggest risk factor of ectopic pregnancy is a previous ectopic pregnancy. Since you are stable now, blood pressure is normal, and no active bleeding and the ectopic pregnancy is not broken, we will manage medically. We will give you a medication, call methotrexate, 89 mg, given with injection to your arm. Methotrexate is a folate derivative that inhibits several enzymes responsible for nucleotide synthesis. This inhibition leads to suppression of inflammation as well as prevention of cell division, which is indicated for abort ectopic pregnancy. During methotrexate treatment, vigorous activity and sexual intercourse should be avoided as this may potentially cause a rupture of ectopic pregnancy. You should avoid folic acid and nonsteroidal anti-inflammatory drugs, like Motrin, because these drugs reduce the efficacy of methotrexate. Gas-forming foods should also be avoided as they may produce pain that can be confused with symptoms of rupture. Once methotrexate has administered, HCG levels should be checked and monitored until they cannot be detected in the blood work. So, we scheduled 2 appointments for you in the clinic, 11/29 and 12/2 for the HCG level check. After you go home, at any given point in time, if you become dizzy, chest pain, having a severe headache, shortness of breath, severe abdominal pain or heavy bleeding, please return to ED immediately.