OB H&P 1:
Identifying information:
Name: KG
Sex: Female
Age: 22
Date: 9/2/2021
Location: Queens hospital center ED
Source of information: self
Referral: self
Mode of transportation: private vehicle
Chief Complaint: Vaginal swelling and tenderness for 3 days
History of Present Illness:
KG is a 22 year old female G0P0 with no significant past medical history, with her LMP of 8/11. She presents to the ED with complaints of swelling and extreme tenderness in her vagina for 3 days. She reports that she was just watching TV at home when she noticed the pain, and denies any trauma to the area. She says the pain is in her left labia majora, with palpable swelling and tenderness. The pain has been worsening since onset as the area has progressively gotten larger, and is a constant sharp sensation. She states the pain worsens when she moves in certain positions and puts pressure on it, and relieves with rest. She says the pain is a 10/10 and does not radiate anywhere. She denies any recent sexual intercourse or exposure to STIs. She denies any fevers, chills, abnormal vaginal discharge, discharge or draining from the swelling, urinary complaints, abdominal pain, or nausea or vomiting. She denies any prior episodes or any similar complaints in the past. OB-GYN team was consulted for possible I&D.
Medical history:
OB history: G0P0
Menstrual history: LMP: 8/11/21. Patient states her menses are regular and last 4 days since starting the transdermal combined contraception 4 months ago. Prior to birth control, her menses were irregular, and at times would skip several months followed by heavy menses. She denies any polymenorrhea, oligomenorrhea, menorrhagia, metrorrhagia, or dysmenorrhea.
GYN history: Patient uses the transdermal combination contraception. Denies any history of STIs, fibroids, endometrial polyps, PID, chronic pelvic pain, abnormal pap screens, or GYN cancer
Medical history: Denies any medical history
Surgical history: Denies any past surgical history
Hospitalization: denies previous hospitalizations
Home meds: denies any regular medications
Allergies: seasonal allergies, NKDA
Social history: 22 year old female, not religious, lives at home with parents. She is single and currently attends college. She denies tobacco, alcohol or any recreational drug use. Denies history of STIs. She is currently sexually active with one parter for the past 1 year, uses condoms for protection.
Family history: Denies any gyn, breast or colon malignancies. Denies family history of CVD, metabolic disease, lung disease, diabetes, thyroid disease, or GI disease.
Review of Systems:
General: patient denies fevers, chills, weakness, unintentional weight loss, night sweats or fatigue.
Head: denies any trauma, headache, dizziness, lightheadedness, loss of consciousness, or changes in balance
Neurologic: denies changes in speech, balance, sensation, numbness, tingling or syncope
Eyes: denies any blurred vision, loss of vision, itching, discharge, photophobia, or swelling
ENT: denies any rhinorrhea, changes in hearing, discharge, vertigo, sneezing, sinus pain, sore throat, swollen lymph nodes, tinnitus or neck pain/stiffness.
Cardiac: denies any chest pain, syncope, diaphoresis, leg edema, heart murmurs, or palpitations
Pulm: denies cough, shortness of breath, dyspnea, pain with inspiration, wheezing or decreased breath sounds
Hematology: denies any easy bleeding or bruising
Skin: denies any lesions, rash, sores, or scars
GI: denies any bowel changes, constipation, diarrhea, abdominal pain, or dysphagia
GU: denies any urgency, frequency, or incomplete voiding, no hematuria, nocturia, or incontinence
Reproductive: admits to vaginal swelling and tenderness, denies any discharge or STIs
MSK: denies joint pain or myalgias
Psych: denies anxiety, suicidal thoughts or depression
Physical exam:
Vitals: BP: 111/73 (left arm sitting), HR: 90, RR: 16, Temp: 98.3 F (oral), O2: 99% on room air, LMP: 8/11.
General: 22 year old female, looks appropriate for age, no acute distress, alert and oriented x 3 to person, place and time, patient is cooperative.
Heart: S1 and S2 present, no murmurs, gallops or rubs. RRR
Lungs: symmetrical breath sounds, clear to auscultation bilaterally, normal chest expansion, no adventitious breath sounds, no wheezes
Abd: No scars or lesions, bowel sounds present in 4 quadrants, soft and nontender
Pelvic exam: performed with chaperone. External genitalia has normal patter. 2x2cm bartholin’s abscess noted on the right on the left, with no overlying erythema or cellulitis on the surrounding mucosa or skin. The area is tender to touch and fluctuant. Speculum exam is deferred due to patient discomfort.
Peripheral vascular: extremities unremarkable, with no palpable cords. No cyanosis. No edema, or signs of DVT.
Neuro: grossly intact to sharp and dull sensation, normal motor function, no movement or gait abnormalities.
Labs:
GC swab: shows no growth
Urine Pregnancy test: negative
Differential Diagnosis:
1. Bartholin’s cyst
- Skene’s gland cyst
- Vestibular mucus cysts
- vaginitis
Assessment:
KG is a 22 year old female G0P0, with no PMHx, presents to the ED with 3 days of left vagianl swelling and tenderness. As per the physical and exam, this is most likely a bartholin’s cyst. OB is consulted for proper management. Patient is stable at this time
Plan:
-OB-GYN Consult
-I&D procedure with packing and discharge instructions
-prescribed augmentin 875mg BID for 7 days
-instructed to do Sitz Baths twice daily
-instructed to return to the ED for any fevers, chills, discharge, bleeding or drainage.
Procedure note:
The OB team was consulted and the swelling was confirmed to be a bartholins cyst with rubor and purulence. An incision and drainage was performed with an attempted word catheter insertion. The patient was counseled on other options such as marsupialization and I&D, and the risks and benefits were discussed and the patient was consented. The patient was draped and pressed in a sterile manner, and the area was anesthetized with 1% lidocaine without epi. A linear incision was made with a #15 blade scalpel and green/yellow purulent material was expressed. A wound culture was taken and the loculations were broken. The abscess was then flushed with sterile saline and a placement of a word catheter was attempted, however it was unsuccessful as it did not remain in place. The cavity was then packed with wound packing, and discharge instructions were given. Patient tolerated the procedure well, with minimum bleeding.
OB H&P 2:
Identifying information:
Name: FS
Sex: Female
Age: 30
Date: 9/3/2021
Location: Queens hospital center ED
Source of information: self
Referral: self
Mode of transportation: private vehicle
Chief Complaint: abdominal pain for 1 day
History of Present illness:
FS is a 30 year old G2P1001 at 6w6d by LMP of 7/16 and a past medical history of a left ovarian cyst presents to the ED with complaints of acute onset abdominal pain for 1 day. She says the pain started this morning while she was waiting for the train. The pain is localized to her left lower quadrant, but is also general at times. The pain is constant, and worsens with certain movements. She describes the pain as being sharp in nature, with intermittent cramping. The pain is usually in the left lower quadrant, but also radiates to her lower back. The pain is exacerbated with movement and palpation of the area and alleviated with rest. At present she rates the pain as a 10/10. She states that two weeks ago she had some mild vaginal spotting, but has since resolved spontaneously. She is also having occasional nausea and vomiting (2x since the morning). She states the vomit is non bloody and non bilious, and had one episode while being examined in the ED. She also reports some trauma to the left flank yesterday after her 5 year old son threw a toy at her. She occasionally feels weak but denies any recent urinary frequency, urgency, dysuria, fevers, chills, night sweats, or a history of STIs. She states the pregnancy is not desired.
OB GYN is consulted, and the patient is found to have reproducible left lower quadrant tenderness. A pelvic exam, bimanual eczema nd transvaginal ultra sound is done, showing possible ectopic pregnancy. Lab results are below.
Medical history:
OB history: G2P1001. X1 LTCS performed at QHC in 2018 for Category 2 FHRT remote from delivery – procedure noted to be uncomplicated
Menstrual history: LMP: 7/16/21. Patient states her menses are regular and last 5 days. She denies any polymenorrhea, oligomenorrhea, menorrhagia, metrorrhagia, or dysmenorrhea.
GYN history: Prior history of left ovarian cyst which was removed at the time of last C-section (2018). Denies any history of fibroids, endometrial polyps, STI, PID, chronic pelvic pain, abnormal pap smear, or GYN cancer.
Medical history: Denies any medical history
Surgical history: X1 LTCS in 2018 at QHC- uncomplicated
Hospitalization: hospitalized in 2018 for C-section
Home meds: denies any regular medications
Allergies: seasonal allergies, NKDA
Social history: 30 year old female, Muslim, lives at home with husband. She is married and does not work. She denies tobacco, alcohol or any recreational drug use. Denies history of STIs. She is currently sexually active with husband for the past 6 years, does not use any barrier protection
Family history: Denies any gyn, breast or colon malignancies. Denies family history of CVD, metabolic disease, lung disease, diabetes, thyroid disease, or GI disease.
Review of systems:
General: Admits to weakness, patient denies fevers, chills, unintentional weight loss, night sweats or fatigue.
Head: denies any trauma, headache, dizziness, lightheadedness, loss of consciousness, or changes in balance
Neurologic: denies changes in speech, balance, sensation, numbness, tingling or syncope
Eyes: denies any blurred vision, loss of vision, itching, discharge, photophobia, or swelling
ENT: denies any rhinorrhea, changes in hearing, discharge, vertigo, sneezing, sinus pain, sore throat, swollen lymph nodes, tinnitus or neck pain/stiffness.
Cardiac: denies any chest pain, syncope, diaphoresis, leg edema, heart murmurs, or palpitations
Pulm: denies cough, shortness of breath, dyspnea, pain with inspiration, wheezing or decreased breath sounds
Hematology: denies any easy bleeding or bruising
Skin: denies any lesions, rash, sores, or scars
GI: Admits to left lower abdominal pain, denies any bowel changes, constipation, diarrhea, or dysphagia
GU: denies any urgency, frequency, or incomplete voiding, no hematuria, nocturia, or incontinence
Reproductive: admits to vaginal spotting, now resolved, and admits to pain in pelvic area. Denies any discharge or STIs
MSK: Admits to back pain, denies joint pain or myalgias
Psych: denies anxiety, suicidal thoughts or depression
Physical Exam:
Vitals: BP: 101/58 (left arm sitting), HR: 74, Resp: 18 (unlabored), Temp: 98.3 (oral), SpO2: 98% (on room area)
General: 30 year old female, looks appropriate for age, no acute distress, alert and oriented x 3 to person, place and time, patient is cooperative.
Heart: S1 and S2 present, no murmurs, gallops or rubs. RRR
Lungs: symmetrical breath sounds, clear to auscultation bilaterally, normal chest expansion, no adventitious breath sounds, no wheezes
Abd: Not distended. No scars or lesions, bowel sounds present in 4 quadrants. Positive tenderness in left lower quadrant to light and deep palpation.
Pelvic exam: performed with chaperone. Normal pattern external genitalia, on speculum exam there is no blood or abnormal discharge noted in the vaginal vault, the cervix is seen and is noted to be normal in appearance, on bimanual exam the cervical os is noted to be closed, uterus is retroverted, felt to be normal in size, non tender, no masses or tenderness noted in the right adnexa but patient is tender in the left adnexa no discrete masses felt.
Peripheral vascular: extremities unremarkable, with no palpable cords. No cyanosis. No edema, or signs of DVT.
Neuro: grossly intact to sharp and dull sensation, normal motor function, no movement or gait abnormalities.
Labs:
- POC urine: positive
- CBC: WBC|RBC|Hb|Hct|Platelets 10.06|4.43|11.7|37.6|330
- BMP: Na|K|Cl|CO2|BUN|Cr|Glu 135|4.7|100|21|6|0.54|95
- LFT: Ca|Pro|Bili|Alk phos|ALT|AST| 9.3|7.4|0.3|67|13|16
- HCG Quant: 9,788
- UA:
- pH: 7
- Color: yellow
- Appearance: clear
- Glucose: negative
- Bilirubin: negative
- Ketones: 40
- Specific gravity: 1.021
- Blood urine: neg
- Protein: neg
- Leuk: negative
- WBC: 0-4
- RBC: 0-3
- Type and screen:
- ABO: AB
- Rh factor: positive
- Antibody: negative
Imaging:
US pelvis tranvaginal:
Impression: Single intrauterine sac like structure without definite yolk sac or fetal pole at this time. Therefore, an ectopic pregnancy cannot be definitively excluded on this study. Large simple appearing left ovarian cyst.
US Pelvis transabdominal:
Impression: Single intrauterine sac like structure without definite yolk sac or fetal pole at this time. Therefore, an ectopic pregnancy cannot be definitively excluded on this study. Large simple appearing left ovarian cyst. Appropriate follow up recommended.
Differential Diagnosis:
- Ectopic pregnancy
- Ovarian torsion
- Ovarian cyst
- Inevitable abortion
- Endometriosis
Assessment:
FS is a 30 year old female who is G2P1001 at 6w6d with a PMH of left ovarian cyst, who presents to the ED for 1 day of acute left lower abdominal pain. Her history, physical exam and lab studies are most likely consistent with ectopic pregnancy. The patient will be admitted for emergency surgical management for likely ectopic pregnancy.
Plan:
- Repeat labs and obtain blood from blood bank
- Keep patient NPO
- Consent her on the procedure an the emergent nature of the management.
- Take patient to the OR as soon as possible for removal of ectopic pregnancy.
Surgical followup note:
A laparoscopic procedure was performed following all sterle guidelines. During the procedure the patient was found to have left ovarian torsion, and a left 7cm ovarian cyst. An ectopic pregnancy was not identified. A laparoscopic ovarian cystectomy, left ovarian detorsion and lysis of adhesions was performed. There were no complications during this procedure and the patient tolerated it well, with minimum blood loss.
Discharge instructions:
- Take 800mg motrin TID as needed for abdominopelvic cramping pain
- Do not place anything in the avagina untl next follow up appointment.
- Return to ED if there is heavy vaginal bleeding, abdominal pain, fever. Chest pain, difficulty urinating or difficulty breathing.
OB H&P 3:
Identifying information:
Name: DF
Sex: Female
Age: 30
Date: 9/9/2021
Location: Queens hospital center ED
Source of information: self
Referral: self
Mode of transportation: private vehicle
Chief Complaint: vaginal bleeding for 2 days
History of Present illness:
DF is a 33 year old female who is G5P1041 at 6w5d with a LMP of 7/21/21 and no other significant past medical history who comes in to the ED with complaints of vaginal spotting for 2 days. She says the bleeding started yesterday when she was at home cooking dinner. The patient also has minimal abdominal and pelvic pain, that is defuse. She says the pain is dull in character and comes and goes with certain movements. She describes the vaginal bleeding as brown at first, and is now pink. She says the bleeding starting as mild clots but has now become heavy. She soaks up to 2 medium sized pads a day. She says that her last miscarriage was 3 months ago, and she had a similar pattern of abdominal pain and vaginal bleeding. The pain does not radiate and she rates it a 6/10 at its worst. It is exacerbated by certain movement and is alleviated with rest and pain medication. She denies any fevers, chills, urinary dysuria, urgency or frequency, recent exposure to STIs, chest pain, shortness of breath, dizziness, or palpitations. She had a beta HCG level done 4 days prior from a private lab, which was 439, and had no sonogram done. She says that this is a desired pregnancy.
Medical history:
OB history: G5P1041, C-section x 1 (2011), Termination of pregnancy x 3, Spontaneous abortion x 1.
Menstrual history: Menses is regular and lasts 5 days. LMP was 7/21/21. She denies any polymenorrhea, oligomenorrhea, menorrhagia, metrorrhagia, or dysmenorrhea.
GYN history: Admits to positive history of HPV last year, but the most recent pap this year was normal. Denies any prior history of fibroids, endometrial polyps, STI, PID, chronic pelvic pain, abnormal pap, GYN cancer.
Medical history: GERD (as of 2013)
Surgical history: C/S X 1 (2011), D&C X 2 (in 2014 and 2016), Cholecystectomy (2017)- all procedures were done at QHC, with no complications.
Hospitalization: hospitalized for the procedures listed up.
Home meds: Pantoprazole (for GERD since 2013)-compliant
Allergies: seasonal allergies, NKDA
Social history: 33 year old female, Muslim, lives at home with husband. She is married and does not work. She denies tobacco, alcohol or any recreational drug use. Denies history of STIs. She is currently sexually active with husband for the past 8 years, does not use any barrier protection
Family history: Denies any gyn, breast or colon malignancies. Denies family history of CVD, metabolic disease, lung disease, diabetes, thyroid disease, or GI disease.
Review of systems:
General: patient denies weakness, fevers, chills, unintentional weight loss, night sweats or fatigue.
Head: denies any trauma, headache, dizziness, lightheadedness, loss of consciousness, or changes in balance
Neurologic: denies changes in speech, balance, sensation, numbness, tingling or syncope
Eyes: denies any blurred vision, loss of vision, itching, discharge, photophobia, or swelling
ENT: denies any rhinorrhea, changes in hearing, discharge, vertigo, sneezing, sinus pain, sore throat, swollen lymph nodes, tinnitus or neck pain/stiffness.
Cardiac: denies any chest pain, syncope, diaphoresis, leg edema, heart murmurs, or palpitations
Pulm: denies cough, shortness of breath, dyspnea, pain with inspiration, wheezing or decreased breath sounds
Hematology: denies any easy bleeding or bruising
Skin: denies any lesions, rash, sores, or scars
GI: Admits to lower abdominal pain, denies any bowel changes, constipation, diarrhea, or dysphagia
GU: denies any urgency, frequency, or incomplete voiding, no hematuria, nocturia, or incontinence
Reproductive: admits to vaginal spotting, and admits to pain in pelvic area. Denies any discharge or STIs
MSK: denies joint pain or myalgias
Psych: denies anxiety, suicidal thoughts or depression
Physical Exam:
Vitals: BP: 101/62 (left arm sitting), HR: 76, Resp: 18 (unlabored), Temp: 9.5 (oral), SpO2: 100% (on room area)
General: 33 year old female, looks appropriate for age, no acute distress, alert and oriented x 3 to person, place and time, patient is cooperative.
Heart: S1 and S2 present, no murmurs, gallops or rubs. RRR
Lungs: symmetrical breath sounds, clear to auscultation bilaterally, normal chest expansion, no adventitious breath sounds, no wheezes
Abd: soft, nontender, normal bowel sounds, no rebound tenderness, guarding or rigidity.
Pelvic exam: performed with chaperone.
VULVA: normal appearing vulva with no masses, tenderness or lesions
VAGINA: normal appearing vagina with normal color and discharge, no lesions
CERVIX: Os closed, 10 ml dark blood seen in vaginal vault , normal appearing cervix without discharge or lesions
UTERUS: uterus is 6 weeks size, shape, consistency and nontender
ADNEXA: normal adnexa in size, nontender and no masses
Peripheral vascular: extremities unremarkable, with no palpable cords. No cyanosis. No edema, or signs of DVT.
Neuro: grossly intact to sharp and dull sensation, normal motor function, no movement or gait abnormalities.
Labs:
- POC urine: positive
- CBC: WBC|RBC|Hb|Hct|Platelets 8.94|4|12.1|36.6|273
- BMP: Na|K|Cl|CO2|BUN|Cr|Glu 135|4.2|101|23|10|0.66|94
- LFT: Ca|Pro|Bili|Alk phos|ALT|AST| 9.6|7.2|0.3|62|11|15
- HCG: 580.5 (on 9/9/21)
- UA:
- pH: 6.5
- Color: yellow
- Appearance: clear
- Glucose: negative
- Bilirubin: negative
- Specific gravity: 1.011
- Blood urine: large
- Protein: neg
- Leuk: large
- WBC: 21-50
- RBC: 7-10
- Type and screen:
- ABO: B
- Rh factor: positive
- Antibody: negative
Imaging: 9/9/2021
Transabdominal study:
Impression: The uterus measures approximately 10.6 x 4.7 x 4.5 cm. There is poor visualization of the uterus and bilateral adnexa. An intrauterine pregnancy is not visualized. The ovaries are not visualized. Ectopic pregnancy cannot be excluded based on this study. Small amount of free pelvic fluid is suggested.
Transvaginal study:
Impression: The uterus measures approximately 8.3 x 4.6 x 5.3 cm. There is poor visualization of the uterus and left adnexa. An intrauterine pregnancy is not visualized. Ectopic pregnancy cannot be excluded based on this study. The right ovary measures approximately 3 x 1.5 x 2.4 cm. A complex right adnexal cyst measures approximately 1.7 x 1 x 1.4 cm. Small amount of free pelvic fluid is suggested.
Differential Diagnosis:
- Threatened abortion
- Ectopic pregnancy
- Early pregnancy
- Functional uterine bleeding
- Spontaneous abortion
Assessment:
DF is a 33 year old female who is G5P1041 at 6w5d with complaints of vaginal bleeding for 2 days. Vital signs are stable, however history, physical exam and labs and imaging suggest early signs of pregnancy of unknown location. Cannot rule out threatened abortion vs ectopic pregnancy.
Plan:
- Repeat BetaHCG levels after 48 hours to see if there is a change.
- Start patient on progesterone.
- Obtain a repeat CBC, CMP and LFT
- Send home with discharge instructions to return to the ED for worsened menstrual bleeding, fevers, chills, dizziness, or severe abdominal pain.
- Patient is to follow up with GYN after 48 hours with a repeat HCG
