Date: 04/05/2022

Full name: T.B

Address: Flushing, NY

Date of Birth: 04/1/1994

Location: Queens Hospital Center  

Religion: Christian 

Source of Information: Self 

Reliability: Reliable  

Source of Referral: None 

Mode of Transport: Self 

Chief Complaint: “Pain in my lower abdomen” x 9hrs

History of Presenting Illness:

28 y/o G4P0111 female is pregnant at 34 3/7 weeks with no significant PMHx and presents to the ED today with complaint of lower abdominal pain which she describes as an 8.5/10 suprapubic cramping sensation in the pelvic region. She states the cramping started at 10am and has persisted over the last 9 hrs. She states that she cannot tell if these cramping pains are similar to contractions. She states that she took Tylenol earlier which she felt did not help. She states that nothing makes the pain better or worse. She also tried taking ice water because at her last visit she was advised to do so because she had similar complaints of lower abdominal pain 1-2 weeks ago and she was advised to keep hydrated. She denies any spotting, or bleeding, decrease in fetal movement, recent sickness, sick contacts, fever, nausea, vomiting, visual changes, lightheadedness or leaking of fluids. There are no other complaints at this time.

Past Medical History:

Denies any hx

Past Surgical History:

Denies past surgeries.   



Past OB history: TOP x 1 in 2013, PT NSVD x 2 (2015, 2017) for IUFD @ 36 weeks due to placental abruption, and in 2017 had an IOL @36 weeks because of high risk hx. Pt does not want BTL at this time.

 Past GYN history: Pap smear was normal and HPV co-testing was negative as of 01/25/2022. LMP was 11/04/2021, periods usually would last 4 days with no heavy bleeding. Menarche around 13 y/o.


-Aspirin (Bayer) 81 MG EC tablet 

– Ferrous Sulfate 325 mg tablets

– Prenatal multivitamin 27-1mg tablet

– Sodium Chloride (ocean nasal spray) 0.65% nasal spray 


-Chocolate (previous hx of hives), NKDA or environmental allergies.

Family History:

Mother – History of HTN at 53, both currently alive

Father – Hx of DM at 45, currently alive 

Sister – No significant past medical hx, 32 

Social history: 

– Single and lives alone with daughter. 

– No domestic violence reported 

– She is sexually active and has one partner which is a male and states the use a condom and was on OCP prior to pregnancy.

– Admits to alcohol use (1 drink in a month) 

– Admits to Marijuana use 

– Denies ever smoking 

Review of system

General – Denies fever, chills

Skin, hair, and nails – has darkened line along abdomen (linea nigra)

Head – Denies any headache 

Eyes – denies any change in vision 

Ears – denies any ringing in the ears 

Nose /Sinuses – denies any congestion 

Mouth/ throat – denies dryness or cracking

Neck – denies any swelling or pain 

Breast – denies any lumps, or nipple discharge

Pulmonary system – denies any coughing or shortness of breath 

Cardiovascular system – denies any chest pain or palpitations

Gastrointestinal system – complains of lower abdominal cramping, denies, nausea, vomiting

Genitourinary system – denies painful urination 

Menstrual /obstetrical – denies any abnormal bleeding, contractions, or fluid leakage, denies any decrease in fetal movement.

Nervous – denies any light headedness

Musculoskeletal – denies any pain or soreness

Peripheral vascular system – Denies any pain but confirms physiologic swelling in the feet

Hematological – denies any vaginal bleeding

Endocrine system – denies polyuria or nocturia

Psychiatric – denies any depression 

Physical exam:

Vital signs: 

Using machine: BP (right arm) 108/ 65 mmHg

Pulse: 94 bpm RRR

RR: 17 breaths/min unlabored

T: 98.4 F (axilla) 

O2 sat: 100 % on room air 

BMI: Weight: 180 lbs, Height: 5’5 = 30.78

General appearance: Black-American female, is alert and oriented x 3. She is no acute distress and is cooperative. She is dressed appropriately with normal affect but seems slightly anxious.

Skin, hair, and nails: Skin is moist. No clubbing or spoon nails noted.

Head: Atraumatic and normocephalic. 

Eyes: PERRLA. Sclera is white without icterus. 

Ears: No cauliflower ears. 

Nose: Patent bilaterally. 

Mouth: Oral Mucosa is moist.

Neck: Supple, non-tender. 

Throat: Uvula is midline.

Pulmonary: Lungs clear to auscultation bilaterally. No wheezing, rales, or rhonchi.

Cardiovascular: Normal S1 and S2 sounds with regular rate and rhythm. 

Abdominal exam: Soft, Gravid and non-tender. Linea nigra present. No pain elicited on mild palpation.

Breast: Nipples and breast are symmetric. No axillary lymphadenopathy noted.

Genitourinary: Normal external female genitalia. No lesions, redness or sores noted.

Menstrual and Obstetrical: No abnormal bleeding in the vaginal vault. No fluids noted. 

Endocrine system: No goiter noted. 

Neuro exam: No nystagmus or focal deficits. She is alert and Oriented x 3. 

Musculoskeletal: Active and passive ROM present in the in all extremities.

Peripheral vascular system: Mild swelling noted in the lower extremities bilaterally secondary to pregnancy. Extremities were non-tender and warm to touch.

Fetal assessment:

Fetal Heart Rate: 140 bpm

Fundal height: 32 cm

Fetal Movement: present

Fetal is in vertex position on US, AFI is 9.6.


28 y/o G4P0111 female is pregnant at 34 3/7 weeks with no significant PMHx and presents to the ED today with complaint of lower abdominal pain which she describes as an 8.5/10 suprapubic cramping sensation in the pelvic region. BP is normotensive, not on aspirin. Sono 4/05 shows EFW of 2,105g Pt is on Makena, risk of hydrops r/o (3/16 and 3/25), Normal anatomy scan, MsAFP borderline elevated but declined amniocentesis.


  1. Pre-term rupture of membrane and labor: Consider due to hx of pre-term delivery and complaints of lower pelvic pain.
  2. Placental abruptio: consider because of high risk and hx of placental abruption in 2015
  3. Dehydration: it was previous problem noted and she attest that she does not take adequate water.

Problem list:

  1. Pending GBS screening (CBC, Syphilis, HIV completed)
  2. Pending Flu vaccine (Tdap vaccine 03/01/2022, fully covid vaccinated on 03/01/2022) 


  1. Will administer Tylenol for pain: Pain was better after Tylenol.
  2. Will do routine labs CBC, BMP 
  3. On Makena (Hydroxyprogesterone caproate)
  4. Will observe in the hospital and listen for FHR, observe tracing, and do US to r/o placental abruptio
  5. Anatomy sonogram today to follow-up on fetal growth and 
  6. Counseling on diet and need for adequate hydration during pregnancy 
  7. Follow up with routine prenatal care next week. NST scheduled for 4/08