H&P 1:
Identifying Info:
Name: SA
Sex: Female
Date of Birth: 1/21/1972, 49 y/o
Date & Time: 10/21/21, 7:45 am
Location: Queens Hospital Center
Marital status: Married
Source of Information: Self, reliable
Mode of Transport: Self
Chief Complaint: abdominal pain since yesterday at 11:30 pm
HPI:
SA is a 49 y/o G2P0010 F with primary infertility at 18w2d of gestation by embryo transfer with an estimated date of delivery: 3/21/22. Patient presents complaining of intermittent, non-radiating, lower right abdominal pain since last night at 11:30 pm. Since then, it has not worsened. Patient states she hasn’t felt fetal movement since late last night. Denies vaginal bleeding, contractions or leakage of fluid. Denies fever, chills, any sick contacts, N/V, diarrhea, constipation or dysuria.
Prenatal course:
– Patient is a non-clinic pt, prenatal care was in Northwell
– IVF done July 3rd with a donor egg, no complications
– EDD given = 3/21/22
OBHx:
– G2P0010
– Medical TOP (TAB) around 20 years ago at 23 y/o
GYN Hx:
– Primary infertility – conceived via IVF and donor egg
– Denies hx of abnormal pap smear, fibroids, cysts, STI/PID
PMH:
– Present/Childhood illnesses: hypertension
– Immunizations: up to date
PSH: Denies hx of any abdominal surgery
Meds: Labetolol 200 mg daily, Prenatal vitamin (PNV)
Allergies: NKDA
Family Hx: non-contributory
Social Hx: SA is a 49 y/o female, lives with her husband. Denies alcohol, tobacco or illicit drug use. Is sexually active with her husband only. Denies current use of contraception or protection. Denies recent travel.
ROS:
General –Denies fever, chills, night sweats, fatigue, weakness, loss of appetite or recent weight gain or loss.
Skin, Hair, Nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or change in hair distribution.
Head – Denies headache, vertigo, head trauma, unconsciousness, coma or fracture.
Eyes – Denies contacts, glasses, visual disturbances, fatigue, lacrimation, photophobia or pruritus.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.
Nose/Sinuses – Denies discharge, epistaxis or obstruction.
Mouth and Throat – Denies bleeding gums, sore throat, sore tongue, mouth ulcers, voice
changes, dentures. Pt’s last dental exam was 6 months ago.
Neck – Denies localized swelling/lumps or stiffness/decreased range of motion.
Breast – Denies lumps, nipple discharge or pain.
Pulmonary System – Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea or PND.
Cardiovascular System – Denies chest pain, HTN, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur.
Gastrointestinal System – Admits to lower R abdominal pain. Denies change in appetite, intolerance to foods, dysphagia, pyrosis, flatulence, eructation, N/V, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool, stool guaiac/colonoscopy/sigmoidoscopy or pain in flank.
Genitourinary – Denies urinary frequency, change in color of urine, incontinence, hematuria, dysuria, nocturia, urgency, oliguria or polyuria.
Sexual History – Admits to sexual activity. Denies anorgasmia, known sexually transmitted infections or the use of contraception/protection.
Menstrual and Obstetrical – Denies dysmenorrhea, menorrhagia, metrorrhagia, PMS, postcoital bleeding, vaginal discharge, dyspareunia or menopause.
Obstetrical History – G2P0010
Musculoskeletal System – Denies joint or muscle pain. Denies redness, deformity or swelling.
Peripheral Vascular System – Denies intermittent claudication coldness or trophic changes, varicose veins, peripheral edema or color change.
Hematologic System – Denies anemia, easy bruising or bleeding, lymph node enlargement or history of DVT/PE.
Endocrine System – Denies polydipsia, polyphagia, polyuria heat or cold intolerance, goiter or hirsutism.
Nervous System – Denies seizures, loss of consciousness, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesia), ataxia, loss of strength, change in cognition/mental status/memory or weakness.
Psychiatric – Denies depression/sadness (feelings of helplessness, feelings of hopelessness, lack of interest in usual activities, suicidal ideation), anxiety, obsessive/compulsive disorder, or ever seeing a mental health professional.
Physical Exam:
General:
49 y/o F A&O x3. Patient is well-appearing, in significant amount of pain, no acute distress.
Vital signs:
Temp: 98.6 degrees F (oral)
R: 15 breaths/min unlabored
P: 95 beats/min, regular rhythm
BP: 147/93
O2 sat: 100% room air
BMI: 23.6
Skin: Skin was warm, smooth, mild turgor, non-icteric, no lesions, masses, scars, tattoos, thicknesses or opacities.
Nails: Normal color size and shape of the nails. Has proper capillary refill on both the fingers and toes. No spooning, clubbing, beau’s lines fissures, paronychia noted.
Head: Atraumatic, normocephalic. No tenderness or pain on the frontal, temporal, occipital, or parietal areas. No deformities or specific faces noted.
Hair: Good quantity evenly dispersed. Thick hair with no lice or seborrhea noted.
Eyes: Symmetrical OU. Eyebrows and eyelashes even distribution, eyelids have no discharge or swelling, lacrimal glands have no excessive tearing, dryness, enlargement or erythema, lacrimal sac not inflamed or swollen. No strabismus, exophthalmos or ptosis. Sclera white, conjunctiva pink. Visual acuity uncorrected – not obtained Visual fields full OU. PERRLA, EOMs intact with no nystagmus.
Ears: Symmetrical and normal size. No lesions, masses or trauma on external ears. No discharge/foreign bodies in external auditory canals AU.
Nose: Symmetrical, no masses lesions or deformities, trauma or discharge.
Mouth: Lips – Pink, moist; no cyanosis or lesions. Non-tender to palpation. Mucosa – Pink; well hydrated. No masses; lesions noted. Non-tender to palpation. Palate – Pink, well hydrated. Palate intact with no lesions; masses; scars. Teeth – Good dentition and no obvious dental caries noted. Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. Tongue – Pink; well papillated; no masses, lesions or deviation noted. Non-tender to palpation. Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies.
Neck: Trachea midline. No masses; lesions; scars; pulsations noted. No erythema, ecchymosis, or edema. Supple; Tenderness over bilateral cervical paravertebral muscles. FROM
Thorax & Lungs:
Chest – Symmetrical, no deformities, no evidence of trauma. Respirations are unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. No tenderness to palpation.
Lungs – Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. No adventitious sounds. Abdomen Nondistended, Mild abdominal tenderness in right and left lower quadrant and suprapubic area. positive bowel sounds, soft, nontender, no rebound tenderness, guarding or rigidity.
Heart – Normal rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Abdomen – Abdomen flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Tender to palpation in the suprapubic area. Tympanic throughout, no guarding or rebound noted, gravid uterus.. No hepatosplenomegaly to palpation, no CVA tenderness appreciated. Murphy’s sign, Rovsing’s sign and McBurney’s point are all negative.
Musculoskeletal – Normal muscle tone. Normal ROM upper extremity and lower extremity. Strength 5/5 bilaterally for both upper and lower extremities.
Membrane status: Intact
Baby FHR: Absent
Uterine Activity: Absent
Labs:
CBC:
– WBC – 9.01
– RBC – 5.23
– HgB – 15.1
– HCT – 46.0
– MCV – 88.0
– MCH – 28.9
– MCHC – 32.8
– eosinophil abs – 0.07
Imaging:
US OB –
GA (LMP) = 18.4 wks. AUA = 16.3 wks. There is no heart beat documented, fetal edema also visualized. Consistent with fetal demise. Adnexa WNL.
Assessment:
SA is a 49 y/o G2P0010 at 18w2d of gestation with an EDD of 3/21/22 with RLQ pain and no FH noted on exam. Official sono ordered.
49 t/o G2P0010 with IUFD at 18 wks EGA (measuring 16 wks on sonogram)
Plan:
Dilation and evacuation for 10/22
Discussed benefits/risks – opting to proceed with D&E
Patient declines genetic testing
