Identifying Information:

• Name: J.R.
• Sex: Female
• DOB: X/X/2004
• Date: 5/06/2021, 7:00 PM
• Location: Woodhull Medical Center – Emergency Department
• Source of Information: Self and Mother
• Mode of Transportation: Private vehicle

Chief Complaint: Lower abdominal pain x 1 week

History of Present Illness:

16 y/o F, G2P1001, LMP 12/27/2020, EGA 18 4/7 weeks with a PMHx of gonorrhea and chlamydia, who presented to the ED complaining of lower abdominal pain for one week. Patient states the pain has been intermittent and reports it is crampy and a pressure sensation. She reports the pain is a 3/10. She denies any alleviating or aggravating factors. Patient states she did not have this type of pain with her first pregnancy. She states she has not received prenatal care yet for this pregnancy and mother states they just found of the patient was pregnant. Patient reports urinary frequency and urgency but denies fever, chills, shortness of breath, chest pain, palpitations, nausea, vomiting, dizziness, vaginal bleeding, vaginal pain, vaginal discharge, dysuria or other symptoms at this time. Patient states she will be started prenatal care at Downstate Hospital next week. Patient’s first child was NSVD with no complications.

PMHx: gonorrhea and chlamydia. Last HIV negative 7/2020.

Medications: Denies taking any medication

PSHx: none

FMHx: Denies any OBGYN history  

Social History: Denies alcohol or tobacco use. Admits to smoking marijuana daily.

Allergies: No known drug, food or environmental allergies. 

Review of Systems:

Gen: Denies fever, chills, fatigue or weakness

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

CV: Denies chest pain, palpitations, leg swelling.

GI: Admits to lower abdominal pain. Denies distention, nausea, vomiting, constipation or diarrhea.

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

Neuro: Denies headaches or dizziness

Physical Exam:

VS: T 98 F orally, BP 111/68, HR 74, RR 18, O2 sat 100%, Wt 151 lb, Ht 5’5”, BMI 25.10

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

Skin: Warm and dry

HEENT: Normocephalic, atraumatic. Pupils equal and round.

Resp: Clear to auscultation bilaterally

CV: Regular rate and rhythm 

Abd: Soft, nondistended, nontender to palpation. Fundus at level of umbilicus. No rebound or guarding.

Pelvic Exam: Normal external female genitalia. Scant milky white discharge in vaginal vault with no blood noted. Cervical os closed with no CMT. Uterus nontender to palpation. No adnexal tenderness.

Bedside sonogram: Single IUP with positive fetal movement and cardiac activity.  

Differentials: Ectopic pregnancy, intrauterine pregnancy, pelvic inflammatory disease, ovarian cyst  

Assessment:

16 y/o F, G2P1001, LMP 12/27/2020, EGA 18 4/7 weeks, with a PMHx of chlamydia and gonorrhea, complaining of lower abdominal pain that started one week ago. In no acute distress, with no abdominal, uterine, cervical or adnexal tenderness on examination. ED UA with moderate leukocyte esterase, 15-30 WBC, moderate bacteria and many squamous epithelial cells. Bedside sonogram with single IUP with fetal movement and cardiac activity.

Plan:

Discharge the patient

Treat UTI with Keflex 500 mg capsule 4 times a day for 10 days

Advised patient to increase fluid intake

Tylenol for pain as needed

Begin prenatal care – keep scheduled appointment with Downstate for 5/11/2021