Identifying Information:

• Name: S.S.
• Sex: Female
• DOB: X/X/XXXX
• Date: 5/04/2021, 9:30 PM
• Location: Woodhull Medical Center – Emergency Department
• Source of Information: Self
• Source of Referral: GYN Clinic 
• Mode of Transportation: Private vehicle

Chief Complaint: Lower abdominal pain x 5 days

History of Present Illness:

32 y/o F, G4P3003, LMP 3/15/2021, EGA 4-6 weeks, recent c-section 01/9/2021, with a PMHx of chlamydia, who presented to the ED from GYN clinic complaining of right lower/suprapubic abdominal pain and back pain that started five days ago. Patient states she had a positive pregnancy test today and reports she had intercourse on 4/5/2021. She reports the pain started abruptly and describes it as sharp. Since then, she states the pain has been intermittent, sharp and crampy but is worsening. She denies any alleviating or aggravating factors. She reports the pain is currently a 7/10 and reports she was given Tylenol in the ED with no relief. She reports fatigue, one episode of diarrhea yesterday and white nonodorous discharge for two days but denies fever, chest pain, shortness of breath, nausea, vomiting, headache, dizziness, dysuria, hematuria, change in urinary frequency or urgency, vaginal pain or vaginal bleeding. She denies recent travel. Patient states she only has one partner, her husband. Patient’s first and third child were c-sections and second was VBAC. Per ED, patient’s beta-HCG was 16,847.

PMHx: chlamydia 

Medications: Denies taking any medication

PSHx: Cesarean section 1/9/2021 due to persistent fetal bradycardia not responsive to resuscitative efforts

FMHx: non-contributory 

Social History: Denies alcohol, tobacco or drug use 

Allergies: NKDA, allergies to sea bass and shellfish-derived products

Review of Systems:

Gen: Admits to fatigue. Denies fever, chills or weakness

Resp: Denies cough, wheezing, hemoptysis, shortness of breath.

CV: Denies chest pain, palpitations, leg swelling.

GI: Admits to right lower quadrant and suprapubic abdominal pain. One episode of diarrhea yesterday. Denies distention, nausea, vomiting, constipation.

GU: Admits to white nonodorous discharge. Denies polyuria, difficulty urinating, dysuria, flank pain, hematuria, urgency, vaginal pain, vaginal bleeding.

Neuro: Denies headaches or dizziness

Physical Exam:

VS: T 98.2 F orally, BP 115/69, HR 75, RR 20, O2 sat 100%, Wt 132 lb, Ht 5’1”, BMI 24.94

Gen: Alert and oriented, in no acute distress. Resting comfortably on stretcher

Skin: Warm and dry

HEENT: Normocephalic, atraumatic. PERRL.

Resp: Clear to auscultation bilaterally

CV: Regular rate and rhythm  

Abd: Soft, nondistended. Suprapubic and right lower quadrant tenderness.. No rebound or guarding.

Pelvic Exam: Normal external female genitalia. White frothy discharge in vaginal vault. Cervical os closed with no CMT. Uterus about 8 weeks in size with tenderness to palpation. Right adnexal tenderness.

Bedside sonogram: Endometrial stripe noted mid-uterus. No IUP noted. Right adnexal sac with fetal pole positive for fetal heart tones, lesion appears to be in right cornual area.

Differentials: Ectopic pregnancy, intrauterine pregnancy, ovarian torsion, ovarian cyst, nephrolithiasis, pelvic inflammatory disease, appendicitis

Assessment:

32 y/o F, G4P3003, LMP 3/15/2021, EGA 4-6 weeks, recent c-section 01/9/2021, with a PMHx of chlamydia, complaining of right lower/suprapubic abdominal pain and back pain that started five days ago with a beta-HCG of 16,847 in the ED. In no acute distress, with right lower quadrant and suprapubic tenderness, right adnexal tenderness, uterus tenderness and white frothy discharge. H&H stable on CBC – 12.0/37.3, UA with trace protein – otherwise labs unremarkable. Bedside sonogram with fetal pole with fetal heat tones in right cornual area. Patient has right ectopic pregnancy.

Plan:

Admit to GYN for diagnostic laparoscopy

Keep NPO

Consent obtained and witnessed