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Name:
D. K
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Date: 10/19/2018
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Time: 1000 AM
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Age: 22 y/o
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Sex: Female
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SUBJECTIVE
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CC: “I had mild fever, nausea, vomiting, vaginal spotting and pain to my right side since last night.”
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HPI: Patient is a 22-years-old female presents to the office c/o right lower abdominal pain 6-8/10 on scale of pain, since last night, accompanied with nausea, vomiting x 3, small spotting and mild fever. Gynecologic history menarche: at the age of 11, with rhythm 28 x 3, denies any STDs, G0P0A0L0, sexually active, one partner.
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Medications: No.
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PMH: Denies
Allergies: Denies any allergies to food or medication
Medication Intolerances: Denies.
Major traumas: Denies any trauma
Hospitalizations: Denies hospitalizations
Surgeries: Denies Surgeries
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Family History
Mother: Alive, Diabetes well controlled.
Father: Alive, Healthy.
Brothers: 2 Alive and Healthy
Children: None.
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Social History:
Home type: Home.
Marital status: Single
Religion: Catholic.
Tattoos: no
Alcohol: Denies.
Drugs: Denies any Drugs consumption.
Smoker: Non-smoker
Exercise: 30- 45 minutes of walk 3 times a week
Pets: No
Travel: Denies.
Blood Transfusion: Denies
OBSTETRIC/GYNECOLOGICAL HISTORY: Single, sexually active, Heterosexual, denies STI’s, Menarche: at age of 11. LMP: 08/18/2018. 28 for 4 days, regular cycle, plus the spots already described, G0T0P0A0L0, Birth Control: Yes/condom.
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ROS
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General
Denies any weight change in the last past 6 months denies weakness, fatigue report monthly. No distress noted at this moment, responding question in an appropriated mood. No exercise intolerance. Patient report nausea, vomiting x 3, since last night.
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Cardiovascular
Patient denies chest pain and palpitation. No edema noticed no syncope, no orthopnea.
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Skin
Warm and dry, skin is appropriated color for ethnicity.
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Respiratory
Patient denies cough, dyspnea, wheezing or hemoptysis, no acute distress at this moment.
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Eyes
Denies changes in vision, no blurred vision, no diplopia, no tearing, no scotomata, and no pain.
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Gastrointestinal
No nauseas, no emesis, no dysphagia, no bowel habit changes, no melena, no constipation.
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Ears
Denies ear pain, hearing loss, ringing in ears, discharge, pearly grey membranes.
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Genitourinary/Gynecological
Denies dysuria, frequency or urgency. Denies blood in urine. No urinary urgency, no change in nature of urine. Vaginal spotting, since last night, no vaginal discharge. OBSTETRIC/GYNECOLOGICAL HISTORY: Single, sexually active, Heterosexual, denies STI’s, Menarche: at age of 9. LMP: 08/18/2018. 28 for 4 days, regular cycle, plus the spots already described, G0T0P0A0L0. Sexually active, one partner.
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Nose/Mouth/Throat
Denies difficulty in smelling, sinus problems, nose bleeds or discharge. Denies dysphagia, hoarseness, or throat pain.
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Musculoskeletal
Denies cramps, joint stiffness, arthritis or gout, limitation of movement, history of musculoskeletal or disk diseases; denies any muscle or joint pain.
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Breast
Denied nipple discharge, breast pain or change in the breast skin.
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Neurological
Denies history of headaches, syncope, seizures, stroke, memory disorder or mood change. No weakness, paralysis, numbness/tingling, tremors or tics, involuntary movements, or coordination problems. No mental disorders or hallucinations.
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Heme/Lymph/Endo
Denies easy bruising or bleeding. No history of anemia, blood transfusions or reactions. Denies exposure to toxic agents or radiation. / Denies heat or cold intolerance, excessive sweating, polydipsia, polyphagia, or polyuria. No history of diabetes, thyroid disease, or hormone replacement.
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Psychiatric
Denies depression, memory changes. Denies suicides attempts or thoughts. No history of mental illness.
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OBJECTIVE
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Weight: 154 lbs
BMI: 26.4
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Temp: 99.8 F
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BP: 100/62 mm/Hg
Pain: 6-8/10
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Height: 5’4’’
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Pulse: 105 bpm
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RR: 22 bpm
O2 Saturation: 99 % at Room air
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General Appearance
Patient is a 22 y/o WHF, appearing of staged age; Alert and oriented; answers questions appropriately. No acute distress at this time. AAOX4, PERRLA; answers questions appropriately. Pain level: 6-/10 on scale of pain.
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Skin
General appearance is normal. Normal temperature, Hydrated, no rashes or lesions described. Intact, warm, moist, good turgor. Screening for skin cancer performed no precancerous skin lesion.
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HEENT
Head normocephalic, atraumatic and without lesions; hair evenly distributed. Throat: Pharynx mildly erythematous, no exudates. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa edematous, clear rhinorrhea, moderate airway obstruction. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist.
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Cardiovascular
No murmur, no rubs or gallop upon auscultation.
Capillary refill 2 seconds. Regular rhythm and rate with S1, S2 normal, no S3 or S4
No edema.
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Respiratory
Symmetric chest wall. Lungs: bilateral mildly, lungs clear upon auscultation, no rales, and no wheezes. Breath sounds equal, no rubs. No respiratory distress noted at this time.
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Gastrointestinal
Abdomen Soft, non-tender, BS normal in all 4 quadrants. No hepatosplenomegaly, mass, or herniation
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Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. No axillary nodes.
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Genitourinary
Genitalia:
The bladder is non-distended; no CVA tenderness.
External genitalia reveal coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. Normally developed female genitalia. No perineal or perianal abnormalities are seen. No genital lesion or urethral discharges. No noted introitus discharge or irritation. No noted introitus discharge or irritation.
Speculum examination: A small speculum was inserted gently, Scan Vaginal bleeding, no cervix discharge, erythema, punctate hemorrhages (strawberry-patch cervix), or friability. Bimanual examination: Mobil cervix with tenderness. Bilateral adnexal palpation very painful Rt>Lf, adnexal masses noted at this time. Pelvis pain increased with a physical examination.
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Musculoskeletal
Steady gait, no limping or musculoskeletal deformities, or muscular atrophy. Thoracic and lumbar spine, normal. Full ROM in all 4 extremities, no joint stiffness.
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Neurological
Speech clear. Good tone. Posture erect. Balance stable; normal gait.
Reflexes 2+ bilaterally throughout.
CN II-XII intact.
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Psychiatric
Good judgment. Alert and oriented. Dressed in clean skirt and blouse. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.
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Lab /Tests/Screening/Intervention/Assessment:
Laboratory /Diagnostic Test Ordered:
Urine Pregnancy test, CBC, BMP, PT/INR, PTT, HCG, Vaginal culture, Abdominal & Pelvic US.
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Special Tests: Not performed.
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Diagnosis
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Ectopic Pregnancy due Clinical Presentation and Physical exam.
1. Ectopic Pregnancy (ICD 10: 000.9)
Ectopic pregnancy is an implantation that occurs in a site other than the endometrial lining of the uterine cavity in the fallopian tube, uterine cornua, cervix, ovary, or abdominal or pelvic cavity. Ectopic pregnancies cannot be carried to term and eventually rupture or involute. Early symptoms and signs include pelvic pain, vaginal bleeding, and cervical motion tenderness. Syncope or hemorrhagic shock can occur with rupture. (Merck Sharp & Dohme Corp 2017)
Differential Diagnostic:
1.- Adnexal torsion: is twisting of the ovary and sometimes the fallopian tube, interrupting the arterial supply and causing ischemia (Merck Sharp & Dohme Corp 2017)
2. – Appendicitis: is acute inflammation of the vermiform appendix, typically resulting in abdominal pain, anorexia, and abdominal tenderness. Diagnosis is clinical, often supplemented by CT or ultrasonography (Merck Sharp & Dohme Corp 2017)
3.- Dysfunctional uterine bleeding is abnormal uterine bleeding that, after examination and ultrasonography, cannot be attributed to the usual causes (structural gynecologic abnormalities, cancer, inflammation, systemic disorders, pregnancy, complications of pregnancy, use of oral contraceptives or certain drugs (Merck Sharp & Dohme Corp 2017)
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Plan/Therapeutics & Education:
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Plan:
1. – Assess hemodynamic stability.
2. – Monitor signs and symptoms of ectopic rupture.
3. – Evaluate contraindication and indication for medical management
4. – Expectant management: Either medical or surgical treatment:
A- Surgical management: salpingostomy or salpingectomy. Surgical management can be done by removal the affected fallopian tube called salpingectomy or by making a hole in the affected fallopian tube and pulling out the ectopic pregnancy and reserving the fallopian tube. If able a laparoscopic surgery is preferred if the patient is hemodynamically stable (Montgomery, Hannon, Muhammad, Das, & Hayes, 2017).
B- Medical management with methotrexate. According to patient’s weight she can have 50 mg methotrexate IM injection followed by lab test CBC, LFT, Beta HCG. After considering lab values especially beta HCG on day four and seven repeat dose of methotrexate. Woman should be advised not to get pregnant at least three months, when they are on methotrexate. Watch patient’s liver function in order to start the treatment and avoid alcohol and folic acid. It is chemotherapeutic agent which causes flatulence, bloating, stomatitis. Most of the patients may experience pneumonitis, bone marrow suppression, pulmonary fibrosis, liver cirrhosis, renal failure and gastric ulceration.
Teaching/Education:
Importance to maintain Hand Hygiene, General Hygiene. Diet habits and life style modification Healthy diet, Normal calorie diet or fat, increased fiber and vegetables in diet. Increase physical activity.
Cervical cancer screening should begin approximately 3 years after a woman begins having vaginal inter- course, but no later than 21 years of age. Screening should be done every year with conventional Pap tests or every 2 years using liquid-based Pap tests.
Follow-up
1. – Patient need to return to clinic if there is no improvement after 48 hours of treatment, or sooner if their condition is worsening.
2. – Follow Dr. orders and in case of emergency please call 911 or come to nearest ER.
3. – Follow up in three weeks after the surgery to evaluated patient, and laboratory testing results.
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Evaluation of patient encounter:
Interview process went well, practitioner elaborated the plan of care with patient, and education was provided and verbalized understanding.
According to Ectopic Pregnancy: Evaluation and Management. Standard Operational Procedures in Reproductive Medicine: Laboratory and Clinical Practice, “The initial evaluation of such patients is a TVS. A TVS is obtained prior to a quantitative hCG as a definitive diagnosis, such as a definite intrauterine pregnancy (IUP) or definite ectopic (EP)”(Shwayder, J. M. (2017).
Approximately 18% of all emergency-department visits for vaginal bleeding and/or acute abdominal pain are associated with ectopic pregnancies. Of these presentations, about 40% to 50% are misdiagnosed.
As signs and symptoms of it are: missed period, pelvic pain, atypical vaginal spotting or bleeding, symptoms of early pregnancy, lightheadedness, syncope, and dizziness. The patient does not know her LMP date, presents with pelvic pain, and irregular bleeding; this is further confirmed by a left adnexal mass with an echogenic ring that is seen separate from the left ovary on the obstetric ultrasound, and a HCG of 1002 (American Pregnancy Association, 2018).
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