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.