OBGYN Nancy Penn/Nancy Penn – OBGYN

OBGYN Nancy Penn Nancy Penn – OBGYN Nancy Penn – OBGYN CC – Pelvic pain Is it possible you’re pregnant/ breast tender/ bleeding between cycles Pretest- actions for acute abdominal pain • Asses forsigns ofshock / hemodynamic instability • Pregnancy test (for all women of childbearing age) • Order blood products immediately in unstable patients with suspected active hemorrhage • Obtain/Preform bedside imaging in unstable patients with suspected pneumoperitoneum or hemoperitoneum. • Administer Antibiotics early in the setting ofsepsis, peritonitis, or perforated viscous • Provide adequate analgesia • Obtain immediate surgical consultation in the setting of an acute abdomen with hemodynamic instability. Diagnosis – Ectopic pregnancy Tests- hcg urine, ua, pelvic ultrasound, cbc Problem Statement: ( Demographic description – chief complaint – Hx and PE key findings – risk factors ) Nancy Penn is a 22 year old female G0P0 presenting with severe stabbing 9/10 diffuse pelvic pain that started 1 hour ago. She is tachycardic (R=120) and hypotensive (89/50 mmHg) and nauseated. Genitourinary exam shows cervical motion tenderness and tenderness to uterine palpation without masses. She is sexually active with her boyfriend and uses condoms inconsistently. She has a history of PID 1 year ago treated successfully and reports her period was 2 months ago and is 1 month late. CC: Nancy Penn is a 22 year old female G0P0 presenting with severe stabbing 9/10 diffuse pelvic pain that started 1 hour ago. HPI: She reported the pain came on suddenly and sharply. She also reports with the pain – nausea and lightheadedness upon standing. Patient reports her last period was 2 months ago. Meds: none. PMH: Patient occasionally smokes, and has a history for pelvic inflammatory disease 1 year ago. SH: Patient is sexually active with her boyfriend and inconsistenly use condoms ROS: Only positive findings are seen in HPI Physical Exam: VS: Pulse – 120 tachycardic; BP – 89/50 hypotensive RR – 20; T – 99F (37 C); SpO2 – 97% Abdominal: no signs of trauma Gynecological: Moderate cervical-motion tenderness, moderate tendernessto direct uterine palpation without masses in adnexa. ASSESSMENT/PLAN Test Results: