Identifying Information:

• Name: K.B
• Sex: Female
• DOB: X/X/1995
• Date: 5/19/2021, 10:30 AM
• Location: Woodhull Medical Center – OBGYN Clinic
• Source of Information: Self
• Mode of Transportation: Private vehicle

Chief Complaint: “I want my IUD removed.”

History of Present Illness:

26 y/o F, G3P021, LMP 1/18/2021 with a hormonal IUD in place since 2/11/2021 and recent D&E on 1/8/2021 due to IUGR, 2VC and clubbed foot and a PMHx of Vitamin D deficiency, who presents for removal of IUD. Patient states she wants the IUD removed because she wants to become pregnant. Patient states she has not had her menses while having the IUD inserted. She denies any fever, chills, shortness of breath, chest pain, abdominal pain, nausea, vomiting, vaginal bleeding, vaginal discharge or vaginal pain.

PMHx: Vitamin D deficiency 

OBGYN Hx:

• NSVD: 1 (2016)
• C/S: 0
• SpAB: 0
• ETOP: 2 (2015, 2021)
• Denies history of STDs

Medications: Vitamin D

PSHx: D&E in 2021 and 2015

FMHx: Denies any OBGYN history  

Social History: Denies alcohol, tobacco or illicit drug use.

Allergies: NKDA

Review of Systems:

Gen: Denies fever, chills, fatigue or weakness

CV: Denies chest pain, palpitations, leg swelling.

GI: Denies abdominal pain, nausea, vomiting, constipation or diarrhea.

GU: Denies polyuria, difficulty urinating, dysuria, flank pain, hematuria, frequency, urgency vaginal pain, vaginal bleeding or vaginal discharge.

Neuro: Denies headaches or dizziness

Physical Exam:

VS: T 98.8 F orally, BP 107/69, HR 65, RR 16, O2 sat 99%, Wt 106 lb, Ht 4’10”, BMI 22.27

Gen: Alert and oriented, in no acute distress. Sitting comfortably in chair.

Abd: Soft, nondistended, nontender to palpation.

Pelvic Exam:

• Vulva: normal external female genitalia. No lesions, scaling or peeling.
• Vagina: No vaginal bleeding or clots. No abnormal discharge. Normal rugae.  
• Cervix: Os closed. IUD string not visualized. No CMT.
• Uterus: nontender to palpation
• Adnexa: no adnexal tenderness or masses noted.

Assessment:

26 y/o F, G3P021, LMP 1/18/2021 with a hormonal IUD in place since 2/11/2021 who presents for removal of IUD. IUD string not visualized on exam. Patient denies the IUD falling out prior to her visit today.

Plan:

Pelvic and transvaginal US ordered to confirm presence of IUD.

Prescribed prenatal vitamins

Return to clinic after sonogram completed