Identifying Data :

Full Name: Ms. SS

Address: Brooklyn, NY

Date of Birth: 8/6/1984

Age: 37 yo

Date & Time: February 23, 2022 2:00 PM

Location: Woodhull Hospital, Brooklyn NY

Religion: None
Source of Information: Self

Reliability: Good
Source of Referral: Self – admitted with husband to emergency room

Chief Complaint : “Bleeding and hurting so bad after abortion.” x1 day

History of Present Illness

37 yo female patient G2P1011 with PMHx of D&C abortion, spontaneous abortion, anemia, gestational hypertension, and pre-diabetes presents to the Emergency Room complaining of heavy vaginal bleeding and lower abdominal pain after an elective dilation and curretage abortion procedure performed on 2/19/2022. She was discharged home and took Acetaminophen (Tylenol) every 8 hours and Ibuprofen (Mortin) every 6 hours. However, she continued to bleed bright red blood with passage of large clots. Patient says she changes her pads 3 – 4 times a day for the bleeding. The abdominal pain is sharp, constant, and rated an 11/10 that causes her to lie in the fetal position at all times. She describes that the pain intensifies several times a day with an intense throbbing and pulsating sensation. Patient experiences fever and diaphoresis and has to pause several times to deep breathe while accounting symptoms. Denies chest pain, palpitations, shortness of breath, dizziness, headache nausea, vomiting, constipation, diarrhea, or urinary symptoms. Denies recent travels.

Past Medical History

• Anemia
• Gestational Hypertension
• Pre-Diabetic
  

Past Surgical History

•  Dilation & Curettage – 2/19/22
•  3 other termination of pregnancies – Date Unspecified
• Myomectomy for Uterine Fibroids – Date Unknown Medications Currently On :

•  Acetaminophen (Tylenol) 650 mg PO q8 hrs
• Ibuprofen (Motrin) 600 mg PO q6 hrs

Allergies

• No allergies to foods or medications

Family History

• Mother – Aged 60 yo, alive
• Father – Aged 62 yo, alive
• Husband – Aged 38, alive
• Sister – Aged 33, alive
• Daughter, alive
• Son, alive
• Son, alive
• Family history of hypertension and diabetes
• Denies family medical history of cancer or respiratory complications
  

Social History

Patient is a married English & Spanishing speaking 41 yo female who lives with her husband and three children in an apartment in Brooklyn, NY. Patient is currently unemployed and a homemaker. Habits : Patient denies drinking, smoking, and use of drugs.
Travel : Denies recent travel.
Diet : Patient eats a balanced diet of carbs, protein, fruits and vegetables.

Exercise : Patient maintains a sedentary lifestyle. She states that she does not work out and that her physical activity comes from daily steps around the house.

Sexual History : Heterosexual, married, monogomaous, and sexually active. Not currently on birth control and uses condoms occasionally. Denies history of sexually transmitted diseases.

Review of Systems

General – Female patient appears in acute distress and the fetal position due to extraordinary lower abdominal pain. Patient is sweating and moaning with poor pallor. Expresses that she feels very weak. Denies loss of appetite, fever, and chills.

Skin, hair, nails – Presents with sweating. Denies excessive dryness, discolorations, pigmentations, moles, rashes, or pruritus.

Head – Denies headaches, vertigo, head trauma, coma, or fractures.
Eyes – Denies other visual disturbances, use of glasses, lacrimation, photophobia, or pruritus.

Last eye exam – unknown.

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

Nose/sinuses – Denies discharge, obstruction, or epistaxis.

Mouth/throat – Denies bleeding gums, use of dentures, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam – unknown.

Neck – Denies localized swelling/lumps. Denies stiffness or decreased range of motion. Breast – Denies lumps, pain, or discharge.

Pulmonary System – Denies shortness of breath that is alleviated with a daily inhaler. Denies dyspnea, dyspnea on exertion, dry cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

Cardiovascular System – Denies chest pain, palpitations, edema/swelling of ankles or feet, syncope.

Gastrointestinal System – Denies nausea, vomiting, diarrhea, or constipation. Denies intolerance to specific foods, dysphagia, pyrosis, abdominal pain, diarrhea, hemorrhoids, constipation, rectal bleeding.

Genitourinary System – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, awakening at night to urinate or flank pain.

Menstrual and Obstetrical — Menarche age 14. Last menstrual cycle – unknown. Presents with heavy bright red vaginal bleeding with passage of clots from incomplete D&C abortion. Denies abnormal vaginal odor or itching.

G6P1051

Nervous System– Denies seizures, headache, loss of consciousness, or change in mental status / memory.

Musculoskeletal System – Presents with constant sharp lower abdominal pain. Denies muscle weakness, slowness, aching, swelling, erythema, and stiffness.

Peripheral Vascular System – Denies coldness or trophic changes, peripheral edema, or color changes.

Hematological System – History of anemia. Denies ecchymosis, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine System – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, hypothyroidism, excessive sweating or goiter.

Psychiatric – Denies depression and anxiety. Denies history of speaking with a therapist and psychiatrist. Denies current suicidal ideation. Denies homicidal thoughts.

Physical Exam

General: Female patient appears in acute distress and the fetal position due to extraordinary lower abdominal pain. Patient is sweating and moaning with poor pallor. Expresses that she feels very weak. Appears well developed and nourished, but poorly hydrated. Appears stated age.

Skin: Poor pallor. Warm, dry, and poor turgor. Non-icteric, no lesions, masses, scars, tattoos, or bruising.

Nails: Clean cut. Capillary refill is normal and <2 seconds throughout. No clubbing, splinter hemorrhages, beta lines, koilonychia, or paronychia.

Head: Skull is normocephalic and non-tender to palpation. Hair is full, good texture, and good luster.

Eyes: Sclera is white and conjunctiva is a pale pink. Pupils are equal, round, reactive to light. EOMs are full with no nystagmus or strabismus.

Visual Acuity : Uncorrected – 20/20 OS, 20/20 OD, 20/20 OU

Fundoscopy : Red reflex is present. Cup:Disk <0.5 OU. No AV nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU.

Ears: External auditory canals are non-tender to touch. Presence of yellow cerumen. Tympanic membranes are intact with good cone of light. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally.

Nose: Nose and sinuses were non-tender to palpation. No signs of nasal swelling or deviation. Lips: Dry, pale. No cyanosis, masses, lesions, swelling, or fissures.

Mucosa: Pink, dry. No masses lesions noted. No leukoplakia. No thrush.
Palate: Pink, dry. No lesions, masses, scars.
Teeth: Teeth intact, no dentures. White and no cavities.
Gingivae: Pink, moist. No hyperplasia, recession, masses, lesions, erythema or discharge. Tongue: Pink, well papillated. No masses, lesions, or deviation.

Oropharynx: Well hydrated. No exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate, Grade 0. Uvula pink, no edema.

Neck – Trachea midline. No masses, lesions, scars, pulsations noted. Supple, non-tender to palpation. Good range of motion. No cervical adenopathy noted. Lymph nodes are mobile, discrete, and non-tender to palpation.

Thyroid – Non-tender to palpation. No palpable masses or thyromegaly.

Chest: Symmetrical. No deformities or trauma. Respirations are unlabored. No paradoxic respirations or use of accessory muscles. Lateral to AP diameter 2:1. Non-tender to palpation throughout.

Respiratory: Clear to auscultation and percussion bilateral. Chest expansion and diaphragmatic excursion symmetrical. Tactile remits are symmetric throughout. No adventitious sounds.

Cardiovascular: JVP is 2 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Abdominal: Unable to palpate lower abdomen due to acute distress and severe abdominal pain. Abdomen is round with no striae or pulsations. Bowel sounds normoactive in all four quadrants. No CVA tenderness.

Genitalia : Heavy vaginal bleeding with passage of clots. External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, or erythema. Cervix multiparous, pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. Pap smear scheduled for next annual GYN exam. No inguinal adenopathy.

Rectal : Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative.

Neurologic:
Mental Status: The patient is alert, attentive, and oriented. Speech is clear and fluent with good

repetition, comprehension, and naming. Recalls 3/3 objects in 5 minutes.

Cranial Nerves :

CN I : Olfaction is intact by identifying the smell of coffee grounds and vanilla extract.

CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs and no vascular changes. Venous pulsations are present bilaterally. Pupils are 3-5 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally.

CN III, IV, VI: At primary gaze, there is no eye deviation. When the patient is looking to the left, the right eye does not adduct. When the patient is looking up, the right eye does not move up as well as the left. Negative for diplopia and ptosis. Convergence is intact.

CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally. Corneal responses are intact.

CN VII: Face is symmetric with normal eye closure and smile. Taste of salty & sweet is present in anterior 2/3 of the tongue.

CN VIII: Hearing is intact. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally.

CN IX, X: Palate elevates symmetrically. Phonation is normal.
CN XI: Head turning and shoulder shrug are intact.
CN XII: Tongue is midline with normal movements and no atrophy.

Motor/Cerebellar :

Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout. Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Sensory :

Intact to light touch, sharp/dull, and vibratory sense throughout. Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.

Reflexes :

Brachioradialis Triceps
Biceps Abdominal

Meningeal Signs :

RL RL

2+ 2+ 2+ 2+ 2+ 2+ 2+/2+ 2+/2+

Patellar
Achilles
Babinski
Clonus negative

No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative.

Muscoloskeletal : Unable to palpate lower abdomen due to patient’s acute distress and severe abdominal pain. No erythema, ecchymosis, atrophy, or deformities in bilateral upper and lower extremities. Full active range of motion with no crepitus in all upper extremities and left lower extremities. Full spinal range of motion with no deformities.

Vitals

Blood Pressure – 124/75
Temp – 99.4 °F

SpO2 – 97%

RR – 18

Height – 5’ 7”

Weight – 175 lbs

BMI – 27.4

Assessment & Plan

37 yo female patientwith PMHx of D&C abortion, spontaneous abortion, anemia, gestational hypertension, and pre-diabetes presents to the Emergency Room complaining of heavy vaginal bleeding and lower abdominal pain after an elective dilation and curretage abortion procedure performed on 2/19/2022. Exam is positive for heavy vaginal bleeding and lower abdominal pain and cramping.

Problem List :

• Heavy vaginal bleeding
• Lower abdominal Cramp
• Weakness
• Fever
• Sweating

D/Dx :

1. Incomplete Abortion – The patient is most likely to have an incomplete abortion as she had a D&C 4 days prior to admission to the ED. If there are still products of conception retained in the uterus, they may become infected and lead to fever, sweating, abdominal pain, and continual vaginal bleeding.
2. Endometritis – Endometritis refers to infection of the decidua and is a common cause of postpartum fever and uterine tenderness. The infection may also extend to the peritoneal cavity, causing severe abdominal pain. It is possible that the D&C procedure was not sterile or exposed the uterus and led to infection.
3. Uterine Perforation – There is always a risk of perforation during intrauterine procedures that injures the uterine tissue and blood supply. Complications are likely if the perforation becomes infected. Pelvic
4. Leiomyoma– The patient may also have myomas that can lead to vaginal bleeding and abdominal pain. However, this is lower on the D/Dx list as it would not account for the signs of infection such as fever and sweating. The more likely scenario would be the presence of infection with myomas contributing to vaginal bleeding.
5. Pelvic Inflammatory Disease – There is a possibility that the patient has a history of undiagnosed pelvic inflammatory disease. PID is rare during pregnancy, but can occur in the first 12 weeks of gestation. As a result, there is a possibility that the patient experienced an upper reproductive tract infection that was exacerbated by D&C.

Plan :

Admit the patient for continuous monitoring. Initiate daily blood tests and labs to trend her H/H and ensure that she is hemodynamically stable. Administer IV fluids and consider transfusion. Consult the surgical team for dilation & curettage for incomplete aboration.

1. Transvaginal Sonogram

1. Order sonogram to visualize any remnants of product of conception (POC)

2. Urine Test, EKG, & Labs

1. Rule out urinary tract infection
2. Rule out cardiac complications for surgery
3. Assess for CBC and H/H status for transfusion and IV fluid administration

3. Medications

1. Initiate Medroxyprogesterone (Provera) to minimize bleeding
2. Consider Gentamicin (Garamycin) 5 mg/kg every 24 hours for infection and fever
3. Prepare Packed Red Blood Cell transfusion if Hemoglobin falls < 7 g/dL or presents with unstable signs and symptoms at 7 – 8 g/dL

4. Surgery Consultation

1. Consult surgical team for dilation & curettage if sonogram shows remnants of product of consumption and patient continues to bleed