History of Present Illness:

25 y/o F, G1P1 with no PMHx, who presents to the ED c/o vaginal bleeding x 3 days. Patient states her LMP was on 2/14/21. She reports one clot when wiping yesterday and blood in the toilet but denies soaking pads. She also reports vaginal pain and lower abdominal pain with no radiation, that is exacerbated when trying to have a bowel movement. Patient states she took Ibuprofen for the pain five hours ago, with minimal relief. Patient states the pain and bleeding is different than her normal menstrual cycle. She states she is monogamous with one male partner. Patient states condoms are not always used, but denies concerns for a STD. She denies fever, chills, chest pain, SOB, nausea, vomiting, vaginal discharge, hematuria, hematochezia, constipation, diarrhea, dizziness or other symptoms at this time.

PMHx: none

Medications: none

Allergies: NKDA

PSHx: none

PFHx: none

Social history: Drinks about three beers a month. Denies tobacco or drug use.

Review of Systems:

General: Denies fever, chills, fatigue, recent weight loss/gain or loss of appetite

             Eyes: denies any visual disturbance

Pulm: denies SOB, hemoptysis, cough, sputum production

CV: denies chest pain, palpitations, edema, syncope

GI: Admits to lower abdominal pain and abdominal pain with BM. Denies change in appetite, nausea, vomiting, diarrhea, constipation, hematochezia

GU: Denies change in frequency, urgency, polyuria, dysuria, hematuria. Sexually active with one male partner, with occasional contraception use. Denies a history of STDs.

Menstrual and Obstetrical: LMP 2/14/21. Admits to vaginal bleeding with a clot. Reports regular intervals between periods. Denies dysmenorrhea, menorrhagia, vaginal discharge, odor or itching. G1P1.

Nervous System: Denies seizures, headache, loss of consciousness, sensory disturbances, weakness

Hematologic System: Denies anemia or easy bruising or bleeding

Physical Exam:

Vitals: T 98.3 F, BP 121/63, RR 18, HR 85, O2 saturation 100%, Ht 4’8”, Wt 91 lbs, BMI 20.4

Gen: Alert and oriented, in no acute distress. Well-groomed and appropriately dressed. 

HEENT: normocephalic, atraumatic, mucous membranes moist, EOMI, PERRLA

CV: Regular rate and rhythm

Pulm: Clear to auscultation bilaterally

Abd: Soft, flat, nondistended, mild tenderness to left lower abdomen with palpation

GU: External genitalia normal with no vaginal discharge. Speculum exam with vaginal discharge and scant blood at cervical os. No adnexal tenderness or CMT.

Neuro: no focal deficit

Psych: normal mood and behavior

 Assessment:

25 y/o F, G1P1 with no PMHx, who presents to the ED c/o vaginal bleeding x 3 days with mild left lower abdominal pain to palpation and GU exam with scant blood at cervical os.

Differentials:

Ectopic pregnancy, ovarian cyst, menstrual bleeding, threatened abortion

Plan:

Urine HcG

UA

CBC

Transvaginal US

Addendum:

Patient not pregnant. UA shows large amount of leukocyte esterase, RBCs and protein. CBC WNL, no leukocytosis or anemia. Transvaginal US with small left sided hemorrhagic ovarian cyst and small amount of free fluid in the cul-de-sac.

Disposition:

            Diagnosis: Left hemorrhagic ovarian cyst, UTI

Patient will be discharged home with Bactrim 800-160 mg per tablet for 7 days.

Take Ibuprofen as needed for pain.

Patient Education:

You have a urinary tract infection, which is caused by bacteria. Your ultrasound also showed a cyst on your left ovary that ruptured or burst.

Take Bactrim 1 tablet by mouth every 12 hours for 7 days. Complete the entire course of antibiotics for your urinary tract infection.

Take Ibuprofen as needed for your lower abdominal pain.

Come back to the emergency department for any worsening symptoms including fever, chills, nausea, vomiting, abdominal pain.