PAMELA FLOWERS – OBGYN
CC: abnormal vaginal bleeding and LLQ pelvic pain
Gynecological exam shows tenderness and L- adnexal fullness (no mass) w/ enlarged + soft uterus.
Patient has history of irregular periods.
DDX
Endometriosis
tubo-ovarian abcess
Pelvic inflammatory disease
ovarian cyst
ectopic pregnancy
abortion
ovarian torsion
dysmenorrhea-primary
Problem Statement:
( Demographic description – chief complaint – Hx and PE key findings – risk factors )
She has a history of dysparenuria on her left side.
HPI: The vaginal bleeding and pain started 1 day prior. Patient also describes dyspareunia 1 week ago,
and has history of ‘irregular periods’
Meds: inhaler for asthma
PMH: Pap smear + gyn exam 8mo ago normal – treated for chlamydia infection 3 years ago.
SH: one current sexual partner, condoms for contraception.
ROS: Only positive findings are seen in HPI
Physical Exam:
VS: Pulse – 104; BP – 108/60 RR – 14; T – 98.8F (37 C); SpO2 – 98%
Gynecologic: Tenderness noted to bimanual exam. Left Adnexal fullness seen without mass. Uterus is
enlarged and softened.
ASSESSMENT/PLAN
Test Results:
• Human chorionic gonadotropin (hCG), plasma: Value consistent with 5-6 w normal
, gestation, suggest transvaginal ultrasound.
• TVUS: high probability of left fallopian tube ectopic pregnancy
• LFTs: Normal (allows her to be Methotrexate candidate)
Management Plan
CC: abnormal vaginal bleeding and LLQ pelvic pain
Gynecological exam shows tenderness and L- adnexal fullness (no mass) w/ enlarged + soft uterus.
Patient has history of irregular periods.
DDX
Endometriosis
tubo-ovarian abcess
Pelvic inflammatory disease
ovarian cyst
ectopic pregnancy
abortion
ovarian torsion
dysmenorrhea-primary
Problem Statement:
( Demographic description – chief complaint – Hx and PE key findings – risk factors )
She has a history of dysparenuria on her left side.
HPI: The vaginal bleeding and pain started 1 day prior. Patient also describes dyspareunia 1 week ago,
and has history of ‘irregular periods’
Meds: inhaler for asthma
PMH: Pap smear + gyn exam 8mo ago normal – treated for chlamydia infection 3 years ago.
SH: one current sexual partner, condoms for contraception.
ROS: Only positive findings are seen in HPI
Physical Exam:
VS: Pulse – 104; BP – 108/60 RR – 14; T – 98.8F (37 C); SpO2 – 98%
Gynecologic: Tenderness noted to bimanual exam. Left Adnexal fullness seen without mass. Uterus is
enlarged and softened.
ASSESSMENT/PLAN
Test Results:
• Human chorionic gonadotropin (hCG), plasma: Value consistent with 5-6 w normal
, gestation, suggest transvaginal ultrasound.
• TVUS: high probability of left fallopian tube ectopic pregnancy
• LFTs: Normal (allows her to be Methotrexate candidate)
Management Plan
