CHIEF COMPLAINT: The patient presents to the emergency room this morning complaining of lower abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient states that she has been having vaginal bleeding more like spotting over the past month. She denies the chance of pregnancy although she states that she is sexually active and using no birth control.
GYNECOLOGIC HISTORY: Patient is gravada 2, para 1, abortus 1. Her only child is a 15-year-old daughter who lives in Texas with her grandmother.
PAST MEDICAL HISTORY: Positive for Hepatitis B.
PAST SURGICAL HISTORY: Pilonidal cyst removed in the remote past. Had plastic surgery on her ears as a child.
SOCIAL HISTORY: Married, has 1 daughter; patient works as a substitute teacher. Smokes 1 pack of cigarettes on a daily basis. Denies EtOH. Smoked marijuana last night. No IV drug abuse.
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ALLERGIES: Tetanus MEDICATIONS: None
(Continued)
REVIEW OF SYSTEMS: Patient complains of a lower abdominal pain for the past week that apparently got much worse last night and by this morning was intolerable. She is also having some nausea and vomiting. Denies hematemesis, hematchezia, and melena. She has had vaginal spotting over the past month with questionable vaginal discharge as well. Denies urinary frequency, urgency and hematuria. Denies arthralgia. Review of system is otherwise essentially negative.
PHYSICAL EXAMINATION: Vital signs show temperature 97 degrees; pulse 53; respirations 22; blood pressure 108/60.
General: physical exam reveals a well-developed, well-nourished 35 year old white female in a moderate amount of distress at the time of the examination. HEEMT are unremarkable except for poor dentation. Neck is soft and supple. Chest: lungs are clear in all fields. Heart: regular rate and rhythm. Abdomen: soft with positive tenderness of the lower abdominal area. Fundus was not palpable above the pubic area. Left abnexal are more tender than the right.
Vaginal Exam: the cervix is closed. A moderate amount of mucopurulent discharge is noted. The patient would not allow me to perform a bimanual examination due to the pain so the speculum was withdrawn. Extremities: No clot, no edema. Neurologic Exam: Intact oriented x 3. No neurologic deficits.
