Identifying data:

Name: NF

Sex: Female

Age: 20

Date: 6/30/21

Location: Queens Hospital Center- Pediatric ER

Source of information: self

Chief complaint: vaginal bleeding X 3 weeks

History of present illness: NF is a 20-year-old female G1P0 8w6d with EDD of 2/3/2022 with past medical history of asthma presented to the ED with a complaint of vaginal bleeding for the past three weeks. LMP  4/29/21. She had a positive pregnancy test at home on 5/29/21. She elected to terminate and went to Women’s choices in Jamaica, on 6/4/21. On 6/4/21 she took one pill at the clinic and 6/5/21 she took 2 pills at home. She was unable to recall the name of pills, or provide any paperwork from the clinic. Patient states she was not given Rhogam by the clinic. Vaginal bleeding began on 6/5/21, and has continued since. The bleeding was heavier, she now describes it as spotting. She uses 2-3 pads daily but is not soaking through them. She has maintained a positive pregnancy test, taking additional at home pregnancy tests three times, the last one this morning. She denies any sexual activity since the termination. She does not use any form of birth control. She denies abdominal pain, cramping, fever, chills, nausea, vomiting, shortness of breath, chest pain, lightheadedness, dysuria, vaginal discharge. She came today because of her persistent vaginal bleeding and persistent positive pregnancy test. Of note the patient was seen in the ED on 6/13/21 for vaginal spotting and abdominal pain, the patient left AMA that day.

ED course:

 Urine pregnancy test in the ED was positive.  TVUS done in the ED showed no definite intrauterine gestation. The uterus was heterogeneous, 7.6X4X6.2cm. There was nonspecific hyperechoic foci within the distal endometrium. The endometrial stripe is heterogeneous 0.9cm. The uterus is vascular. The ovaries 3.5X3.1 X 1.5 cm on the left, 2.7X1.8X1.8 on the right. Flow is noted in both ovaries. Mild pelvic free fluid suggested. An ectopic pregnancy could not be excluded.  The ED consulted the GYN team to rule out an ectopic pregnancy.

OB history: G1P0 s/p TOP on 6/4/21

Menstrual history: LMP 4/29/21.  periods are regular, she says they come every month and last for three days. Denies polymenorrhea, oligomenorrhea, menorrhagia, metrorrhagia, dysmenorrhea.

Gynecological history: denies use of birth control, denies history of STIs, abnormal pap smears, ovarian cysts, uterine polyps or fibroids.

Past medical history: asthma, denies hospitalizations or intubations

Hospitalizations: denies previous hospitalizations

Immunizations: Up to date

Past surgical history: denies past surgical history

Medications: albuterol as needed for asthma symptoms.

Allergies: NKDA

Social history: 20-year-old female, not religious, she is single and lives with her mother. Denies tobacco, alcohol or recreational drug use. Denies history of STIs, not currently sexually active, does not have a current partner.

Family history: denies family history of breast, ovarian or endometrial cancer. Denies family history of cardiovascular disease, metabolic diseases, lung diseases, kidney diseases, thyroid disease, allergies, GI disease.

Review of systems:

General: patient denied nausea, anorexia, general weakness, fever, chills, vomiting, fatigue, diaphoresis, night sweats and changes in weight

Head: patient denied trauma , headache, confusion, lightheadedness, changes in vision, loss of consciousness

Neurologic: patient denied slurred speech, neck stiffness, decreased sensation, numbness, tingling, syncope

Eyes: denied blurred vision, itching, photophobia, discharge, swelling.

ENT: patient denied vertigo, rhinorrhea, stuffiness, sneezing, sore throat, swollen lymph nodes, tinnitus, neck pain

Cardiac: patient denied leg edema, claudication, known heart murmurs, chest pain, shortness of breath, palpitations

Pulmonary: patient denied cough, shortness of breath, pain with inspiration, wheezing, hemoptysis

Hematology: patient denied bruising, anemia

Skin: patient denied rash, sores, itching

GI: patient denied bowel changes, abdominal pain, diarrhea, constipation, dysphagia

GU: patient denied urgency, dysuria, polyuria, hematuria, nocturia, incontinence.

Reproductive:+ pregnancy test, +vaginal spotting. Denies vaginal discharge, history of STIs.

MSK: patient denied joint pain and swelling

Psychiatric: patient denied anxiety, depression, mood changes.

Physical exam:

Vitals: BP 90/60, HR 90, RR 18, T 98.6, O2 saturation: 99%, height 5’3” weight 115 lb, BMI 20.4.

General: 20-year-old female, thin, appears stated age, NAD

Skin: no pallor or rashes, warm and moist, appropriate skin turgor

Heart: S1 and S2 present without murmurs, rubs, gallops, RRR

Lungs: symmetrical chest expansion, CTAB without adventitious lung sounds

Abdomen: non palpable uterus. BS present in all 4 quadrants, soft and nontender

Pelvic exam: performed with resident chaperone. External genitalia unremarkable. Speculum exam: brown discharge noted, no bright red blood. Cervix visualized, with closed os. Bimanual exam: patient was nontender, no masses on the adnexa, uterus palpable.

Peripheral vascular: extremities unremarkable in appearance, size and color. Nontender to palpation. No edema. No signs of DVT.

Neurological: grossly intact. No movement or gait abnormalities.

Imaging:

1. pelvic US: showed no definite intrauterine gestation. The uterus was heterogeneous, 7.6X4X6.2cm. There was nonspecific hyperechoic foci within the distal endometrium. The endometrial stripe is heterogeneous 0.9cm. The uterus is vascular. The ovaries 3.5X3.1 X 1.5 cm on the left, 2.7X1.8X1.8 on the right. Flow is noted in both ovaries. Mild pelvic free fluid suggested. An ectopic pregnancy could not be excluded. 

Labs:

1. Urine pregnancy test: positive
2. CBC: WBC|RBC|Hb|Hct|Platelets    5.48| 4.23| 12.2| 37.5| 333
3. BMP: Na|K|Cl|CO2|BUN|Cr|Ca       139|4.3|104|23|12|0.78}9.6
4. Quantitative beta hcg: 538 on 6/29/21 (on 6/13/21 hcg 356)
5. Type and screen: O negative

Assessment: NF is a 20-year-old female at 8w6d gestation with past medical history of asthma, presented to the ED with three weeks of vaginal bleeding and persistent positive pregnancy test s/p TOP 6/4/21. In view of uptrending hcg and vaginal spotting and no definite IUP on ultrasound, cannot rule out ectopic pregnancy at this time. Patient is Rh negative s/p abortion. Patient has stable vital signs.

Plan:

#vaginal spotting, uptrending hcg

1. Dilation and curettage  scheduled for 7/2/21
2. Repeat hcg 7/2/21
3. Patient desired to leave the ED until scheduled procedure, education given for return precautions including syncope, abdominal pain, increased bleeding, dizziness. Patient verbalized understanding.

#Rh negative status

1. Rhogam injection in the ED today

Differential diagnosis:

1. Ectopic pregnancy
2. Early IUP
3. Retained products of conception/ failed medical termination of pregnancy

H&P 2

Identifying data:

Name: FD

Sex: Female

Age: 38

Date: 7/1/21

Location: Queens Hospital Center- Adult ER

Source of information: self

Chief complaint: Abdominal pain X 2 days

History of Present illness: FD is a 38-year-old female G2P0010 6w0d with PMH of SAB presented to the ED with a complaint of abdominal pain for the past two days. LMP 5/18/21. Abdominal pain began two days ago in the bilateral lower quadrants, described as cramping, intermittent 6/10 pain. Denies exacerbating or alleviating factors. She had associated heavy vaginal bleeding yesterday,  but is not currently bleeding. She changed 3 pads yesterday. She denies fever, chills, nausea, vomiting, urinary symptoms, changes in BM, dizziness, syncope, SOB, chest pain. This has never happened before.

ED course: patient had a positive uHcg. TVUS showed 0.4cm fetal pole in left adnexa, 0.4cm yolk sac, gestational sac measured 2.5X 2.3 cm. FHR 105, and moderate free pelvic fluid was seen. Beta HCG 9,506. ED called GYN consult for left tubal ectopic pregnancy.

OB history: X1 SAB in the first trimester G2P0010

GYN history: menses are regular monthly menses, lasting 5 days. Denies dysmenorrhea or menorrhagia. Denies prior history of fibroids, endometrial polyps, STI, PID, chronic pelvic pain, abnormal pap, GYN cancer.

Past medical history: denies past medical history

Hospitalizations: denies hospitalizations

Immunizations: up to date

Past surgical history:  denies past surgical history

Medications: denies taking medications

Allergies: NKDA

Social history: 38-year-old female,  not religious, married lives with her husband. Denies tobacco, alcohol or recreational drug use. Denies history of STIs, is currently sexually active with her husband only.

Family history: denies family history of breast, ovarian, endometrial, or colonic malignancies. Denies family history of cardiovascular disease, metabolic diseases, lung diseases, kidney diseases, thyroid diseases, allergies, GI disease

Review of systems:

General: patient denied nausea, anorexia, general weakness, fever, chills, vomiting, fatigue, diaphoresis, night sweats and changes in weight

Head: patient denied trauma , headache, confusion, lightheadedness, changes in vision, loss of consciousness

Neurologic: patient denied slurred speech, neck stiffness, decreased sensation, numbness, tingling, syncope

Eyes: denied blurred vision, itching, photophobia, discharge, swelling. Does not wear corrective lenses

ENT: patient denied vertigo, rhinorrhea, stuffiness, sneezing, sore throat, swollen lymph nodes, tinnitus, neck pain

Cardiac: patient denied leg edema, claudication, known heart murmurs, chest pain, shortness of breath, palpitations

Pulmonary: patient denied cough, shortness of breath, pain with inspiration, wheezing, hemoptysis

Hematology: patient denied bruising, anemia

Skin: patient denied rash, sores, itching

GI: + abdominal pain, patient denied bowel changes, diarrhea, constipation, dysphagia

GU: patient denied urgency, dysuria, polyuria, hematuria, nocturia, incontinence.

Reproductive:  + vaginal bleeding Denies vaginal discharge, history of STIs.

MSK: patient denied joint pain and swelling

Psychiatric: patient denied anxiety, depression, mood changes.

Physical exam:

Vitals: BP 124/82, HR 95, RR 16, T 97.4F, O2 saturation 98% RA, height 5’4”, weight 156 lb, BMI 26.8.

General: 38-year-old female, average build, appears stated age, NAD

Skin: no pallor or rashes, warm and moist, appropriate skin turgor

Heart: S1 and S2 present without murmurs, rubs, gallops, RRR

Lungs: symmetrical chest expansion, CTAB without adventitious lung sounds

Abdomen: non palpable uterus. BS present in all 4 quadrants, soft and nontender

Pelvic exam: performed with resident chaperone. External genitalia unremarkable. Speculum exam: no discharge, no blood, Cervix visualized, with closed os. Bimanual exam: slight left adnexal tenderness, no masses palpable.  The OS is closed on the bimanual exam.

Peripheral vascular: extremities unremarkable in appearance, size and color. Nontender to palpation. No edema.

Neurological: grossly intact. No movement or gait abnormalities.

Imaging:

1. TVUS: 0.4 cm fetal pole in left adnexa, 0.4cm yolk sac, gestational sac measures 2.5X2.3 cm, moderate free pelvic fluid noted. FHR 105. Consistent with left tubal ectopic pregnancy.

Labs:

1. Type and screen: A positive
2. Covid: negative
3. CBC: WBC|RBC|Hb|Hct|Platelets      4.15|4.54|12.8|40.9|230
4. Hcg quantitative: 9506
5. BMP: Na|K|Cl|CO2|BUN|Cr|Ca        136|4.5|102|23|7|0.74|10

Assessment: 38-year-old female G2P0010 at 6w0d with left tubal ectopic pregnancy seen on imaging with fetal pole and FHR 105, moderate free pelvic fluid noted. Patient is hemodynamically stable with stable vital signs.

Plan:

# left tubal ectopic pregnancy

1. Hemodynamically and vital signs stable: H&H 12.8 and 40.9. BP 124/82, HR 95.
2. Discussed with patient relative contraindication to methotrexate due to FHR and counseled on the need for laparoscopic. Patient verbalized understanding and agreed to the procedure.
3. Plan for laparoscopic salpingectomy with possible laparotomy
4. IV fluid
5. NPO
6. Type and screen X 2
7. Coagulation labs: PT/INR, PTT