History and Physical 

Name – AS

Age – 33

Race – African American 

Gender- Female 

Date – 04/19/21

Status – Married 

Time – 3:40 a.m.

Location – Queen’s Hospital Center

Source of information- Self (reliable) 

Mode of transport – Personal vehicle 

CC: “My stomach really hurts” x6 hours

HPI: AS is a reliable 33 year-old African American female, G1P0010, with LMP of 04/18/21 (cycle day 1), with past medical history of dysmenorrhea and chronic pelvic pain, recently diagnosed with fibroid uterus, and left adnexal cyst, presents to the emergency room complaining of left lower abdominal pain. Patient states that the pain began at 9:00 pm on 04/18/21, as she was standing up from the toilet. The pain was characterized as sharp, 10/10 radiating to her upper abdomen. It was associated with one episode of vomiting after arriving to the emergency room. Patient states that the pain is aggravated by movements and that the pain “reminds her of when she had food poisoning” four years ago. The pain has improved with Tylenol and Toradol given at 10:35 pm on 4/18/21 in the ED.  Patient states that for many years she has dysmenorrhea on cycle day 1 and 2, which usually improves with naproxen. Today her pain is more severe than her usual dysmenorrhea. Tonight she ate chicken and rice from a take-out Greek restaurant. Patient admits to having “ovary pain” for the last 6 months, every other day or every few days, lasting for 10-20 minutes, and it resolves spontaneously. She did not seek medical attention until 3 weeks ago, when she was told she had fibroids and left ovarian cyst after a sonogram. MRI on 4/9 showed 5 cm left adnexal hemorrhagic cyst, and multiple fibroids. She has an appointment with her private GYN on 4/29 to discuss surgical management via laparoscopy. Patient denies fever, chills, dizziness, palpitations, SOB, or chest pain. At the present moment the patient denies nausea, vomiting, diarrhea or constipation. Patient also denies recent travel or contact with anyone who is sick. 

PMH

Current Illness- Uterine fibroids, ovarian cysts 

Past Medical Illness – None 

Injuries – Right ankle fracture 06/2020

Surgeries- ORIF fibula right, arthroscopy of right ankle 06/2020, Long Island Jewish, no complications. 

Allergies- Allergies to the environment. Denies allergies to food or medication. 

Medications – Naproxen (unsure about the dosage)  taken at home as needed for chronic pelvic pain

Immunizations – Up to date

Diet- Has a normal diet and eats three meals a day.

Past Family/ Social History  

Family History – Denies family history of gynecologic, breast or colon malignancies. Denies diabetes. 

Smoking – Denies smoking e-cigarettes, tobacco, marijuana or any other illicit drugs. 

Substance use – Denies drinking alcohol 

Caffeine- Drinks one cup of coffee a day 

Home- Lives at home with parents are siblings. 

Travel – AS denies any recent travel. 

Review of Systems:

General – Admits to loss of appetite, weakness and fatigue. Denies recent weight gain or loss, fatigue, fever, headaches, or night sweats.

Skin, hair, nails –Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies dizziness, headaches, vertigo or head trauma, head fracture or coma.

Eyes –Denies contacts or glasses, visual disturbances, fatigue, photophobia, and pruritus. Last eye exam x2 year ago- normal.

Ears –Denies deafness, tinnitus, pain, discharge, or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat – Denies bleeding gums, denies dentures, sore throat, sore tongue, mouth ulcers, voice changes. Last dental exam x2 years – normal. 

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion.

Breast- Denies lumps, nipple discharge, and pain.

Pulmonary– Denies dyspnea, DOE, cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, cyanosis and hemoptysis.

Cardiovascular– Denies chest pain, swelling of the extremities, irregular heartbeat, syncope or known heart murmur.

Gastrointestinal– Admits to lower abdominal pain. Denies loss of appetite, nausea, and vomiting. Denies flatulence, eructation, acid reflux and blood in the stool. Denies intolerance to specific foods, constipation, dysphagia, pyrosis, diarrhea, jaundice, hemorrhoids, rectal bleeding, or blood in stool. 

Genitourinary system – Denies urinary frequency, urgency, slight incontinence and nocturia. Denies oliguria, polyuria, dysuria, or flank pain.

Sexual History- Admits to being currently sexually active with her husband. Partners were always male. Avoids pregnancy via timed intercourse. Denies history of sexually transmitted diseases or anorgasmia. 

Obstetrical – G1P0010, LMP 4/18/21. Admits to fibroids and a left ovarian cyst. Admits to one SAB. Menses are regular each month and last for approximately 5 days. Dysmenorrhea, usually on day 1 and day 2. Denies metrorrhagia, menorrhagia, dyspareunia, denies history of sexually transmitted diseases, abnormal pap, or GYN cancer.

Breast- Denies skin changes, lumps, nipple discharge, and pain.

Nervous – Denies seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.

Musculoskeletal system – Denies deformity or swelling, joint or muscle pain, redness or arthritis.

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.

Hematological system – Denies anemia, easy bruising or bleeding. Denies lymph node enlargement, or history of DVT/PE.

Endocrine system – Denies polyuria, polyphagia, polydipsia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric – Denies anxiety, depression/sadness, OCD or ever seeing a mental health professional.

PHYSICAL 

Skin:

Skin was warm, smooth, mild turgor, nonicteric, 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. Very coarse and 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 clear. 

Visual acuity uncorrected – 20/20 OS, 20/20 OD, 20/20 OU

Visual fields full OU. PERRLA, EOMs intact with no nystagmus. 

Fundoscopy – Red reflex intact OU. Cup to disk ratio <0.5 OU. No AV nicking, hemorrhages, exudates or neovascularization OU. 

Ears:

Symmetrical and normal size. No lesions, masses or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. Tympanic membrane pearly white/intact with cone of light in normal position AU. Auditory acuity intact to whispered voice AU. Weber midline/Rinne reveals AC>BC AU.

Nose

Symmetrical, no masses lesions or deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection or perforation. No foreign bodies. 

Sinuses

Non-tender to palpation and percussion over bilateral frontal and maxillary sinuses. 

Mouth

Lips – Pink, moist; no cyanosis or lesions. Non-tender to palpation.

Mucosa – Pink; well hydrated. No masses; lesions noted. Non-tender to palpation. No leukoplakia.

Palate – Pink, well hydrated. Palate intact with no lesions; masses; scars. Non-tender to palpation; continuity intact. 

Teeth – Good dentition and no obvious dental caries noted.

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. Non-tender to palpation.

Tongue – Pink; well papillated; no masses, lesions or deviation noted. Non-tender to palpation.

Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions. 

Neck- Trachea midline. No masses; lesions; scars; pulsations noted. No erythema, ecchymosis, or edema. Supple; Tenderness over bilateral cervical paravertebral muscles.  FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no palpable adenopathy noted.

Thyroid- Non-tender; no palpable masses; no thyromegaly; no bruits noted.

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. Tactile fremitus throughout. No adventitious sounds. 

Abdomen

Nondistended, positive bowel sounds, soft, tenderness in LLQ, no rebound tenderness, guarding or rigidity.

Pelvic exam 

Normal perineum. Speculum exam shows small amount of blood in the vaginal vault; normal appearing cervix. Bimanual exam shows cervical os closed; uterus 8 week sized, retroverted firm, mobile, non-tender; left adnexal tenderness, approximately 4 cm mass. Right adnexal non-tender, no mass present. 

Musculoskeletal

Normal muscle tone. Normal ROM upper extremity and lower extremity. No pronator drift. Strength 5/5 bilaterally for both upper and lower extremities.

Heart

Normal rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. JVP is 2.5 cm above the sternal angle with the head of the bed at 30 degrees. PMI in 5th ICS in mid-clavicular line and not greatly appreciated. Carotid pulses are 2+ bilaterally without bruits.

Labs: 

B-HCG: negative 

CBC: 10>14.7/45.9<217

BMP, Lipase, LFT: Within Normal Limits 

Urinalysis: Contaminated 

Imaging 

Bedside sono: Uterus 8×4.5 cm, 4 x 5 cm intramural fibroid in the anterior uterine wall, and 2 cm subserosal fibroid in the fundus. Left ovary enlarged, 4.5 x 3 cm, heterogeneous appearance, no obvious cyst seen, right ovary not well visualized. Small amount of free fluid in the pelvis. 

Differential Diagnoses 

Assessment – AS is a reliable 33 year-old, G1P0010, with LMP of 04/18/21 (cycle day 1) presents to the ED with lower left abdominal pain that is most consistent with a ruptured left ovarian cyst.  

DDx:

1. Left ovarian cyst rupture
2. Left ovarian hemorrhagic cyst 
3. Left ovarian torsion 
4. Ectopic Pregnancy 
5. Dysmenorrhea 

Plan: 

1. Pain management per ED 
2. Follow up with private GYN as scheduled