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.
Hospitalizations:
Denies.
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.
Medications:
-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
Allergies:
-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.
Assessment:
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.
Differential:
- Pre-term rupture of membrane and labor: Consider due to hx of pre-term delivery and complaints of lower pelvic pain.
- Placental abruptio: consider because of high risk and hx of placental abruption in 2015
- Dehydration: it was previous problem noted and she attest that she does not take adequate water.
Problem list:
- Pending GBS screening (CBC, Syphilis, HIV completed)
- Pending Flu vaccine (Tdap vaccine 03/01/2022, fully covid vaccinated on 03/01/2022)
Plan:
- Will administer Tylenol for pain: Pain was better after Tylenol.
- Will do routine labs CBC, BMP
- On Makena (Hydroxyprogesterone caproate)
- Will observe in the hospital and listen for FHR, observe tracing, and do US to r/o placental abruptio
- Anatomy sonogram today to follow-up on fetal growth and
- Counseling on diet and need for adequate hydration during pregnancy
- Follow up with routine prenatal care next week. NST scheduled for 4/08
