OB/GYN History and Physical 1
Identifying information:
Name: KG
Sex: Female
Age: 34
Date: 10/13/2021
Location: NYC HHC Woodhull ED
Source of information: self through Bengali interpreter
Referral: self
Mode of transportation: private vehicle
Chief Complaint: Vaginal bleeding x 2 days
History of Present Illness:
Bengali interpreter was used, #XXXX
KG is a 34-year-old female G2P1 with no significant past medical history, LMP of 8/12. She is following up to the ED today with complaints of heavy vaginal bleeding, lower abdominal pain, fatigue, and concern that “something feels stuck in” her vaginal canal. Pt states that she was in Woodhull ED 2 days ago for an elective termination of pregnancy, was given misoprostol, and dc’d home to wait for complete expulsion of tissue. States that she was expecting vaginal bleeding but the pain is too unbearable. She describes the pain as 10/10 in her lower abdominal area, notes no relief of pain with ibuprofen 600 mg TID. Endorses that she has only noticed “small clots” over the past 2 days and that “nothing more has come out”. Denies fever, chills, body aches, nausea, vomiting, diarrhea, leakage of fluid, back pain, chest pain, SOB, cough, weight loss, hemoptysis.
Medical history: Denies
OB history: G2P1
Menstrual history: LMP: 8/12/21. Patient states her menses are regular and usually last 4 days. She denies any oligomenorrhea, metrorrhagia.
GYN history: Patient admits to using barrier protection. Denies any history of STIs, fibroids, endometrial polyps, PID, chronic pelvic pain, abnormal pap screens, or GYN cancer
Medical history: Denies any medical history
Surgical history: Denies any past surgical history
Hospitalization: Denies previous hospitalizations
Home meds: Denies any regular medications
Allergies: seasonal allergies, NKDA
Social history: 34 year old female, Muslim, lives at home with husband. She is married and is currently a housewife. Denies tobacco, alcohol or any recreational drug use. Denies history of STIs. She is currently sexually active with one partner for the past year, and uses condoms for protection. Denies OCP use.
Family history: Denies any gyn, breast or colon malignancies. Denies family history of CVD, metabolic disease, lung disease, diabetes, thyroid disease, or GI disease.
Review of Systems:
General: patient denies fevers, chills, weakness, unintentional weight loss, night sweats or fatigue.
Head: denies any trauma, headache, dizziness, lightheadedness, loss of consciousness, or changes in balance
Neurologic: denies changes in speech, balance, sensation, numbness, tingling or syncope
Eyes: denies any blurred vision, loss of vision, itching, discharge, photophobia, or swelling
ENT: denies any rhinorrhea, changes in hearing, discharge, vertigo, sneezing, sinus pain, sore throat, swollen lymph nodes, tinnitus or neck pain/stiffness.
Cardiac: denies any chest pain, syncope, diaphoresis, leg edema, heart murmurs, or palpitations
Pulm: denies cough, shortness of breath, dyspnea, pain with inspiration, wheezing or decreased breath sounds
Hematology: denies any easy bleeding or bruising
Skin: denies any lesions, rash, sores, or scars
GI: denies any bowel changes, constipation, diarrhea, abdominal pain, or dysphagia
GU: denies any urgency, frequency, or incomplete voiding, no hematuria, nocturia, or incontinence
Reproductive: admits to vaginal swelling and tenderness, denies any discharge or STIs
MSK: denies joint pain or myalgias
Psych: denies anxiety, suicidal thoughts, or depression
Physical exam:
Vitals: BP: 131/83 (left arm sitting), HR: 99, RR: 20, Temp: 98.6 F (oral), O2: 97% on room air, LMP: 8/12.
General: 34-year-old female, looks appropriate for age, appears uncomfortable, alert and oriented x 3 to person, place and time, patient is cooperative.
Heart: S1 and S2 present, no murmurs, gallops or rubs. RRR
Lungs: symmetrical breath sounds, clear to auscultation bilaterally, normal chest expansion, no adventitious breath sounds, no wheezes
Abd: No scars or lesions, bowel sounds present in 4 quadrants, soft and nontender to palpation throughout. No guarding, rebound tenderness. – Rovsing’s. – Psoas. – Obturator.
Pelvic exam: performed with chaperone. External genitalia have normal patter. Speculum exam indicates open cervix with active bleeding with tissue extruding from the cervical os. + uterine tenderness, no – uterine enlargement. No adnexal masses, no adnexal tenderness
Peripheral vascular: extremities unremarkable, with no palpable cords. No cyanosis. No edema, or signs of DVT.
Neuro: grossly intact to sharp and dull sensation, normal motor function, no movement or gait abnormalities.
Labs:
bHCG: 201
Differential Diagnosis:
- Retained products of conception (RPOC)
- Gestational trophoblastic disease
- Incomplete Abortion
- Septic RPOC
- Hematometra
- Traumatic termination
- Endometritis
- PID
Assessment:
KG is a 34 year old female G1P1, with no PMHx, presented to the ED with 2 days of vaginal bleeding and lower abdominal pain. As per the physical and exam there is a dilated cervix with tissue extruding from the cervical os with active bleeding and uterine tenderness. Symptoms are most likely due to retained products of conception. Patient is stable currently.
Plan:
- BW
- Type and screen
- GC/C
- CBC
- PT/PTT
- Procedure:
- Transvaginal US
- Dilation and Curettage, IF no response then:
- Uterine tamponade
- Uterine artery embolization
- Hysterectomy
- IVF and pRBC as needed
OB/GYN History and Physical 2
Identifying information:
Name: JO
Sex: Female
Age: 19
Date: 10/19/2021
Location: Woodhull Women’s Health Clinic
Source of information: self
Referral: self
Mode of transportation: private vehicle
Chief Complaint: Vaginal discharge x 2 days
History of Present Illness:
JO is a 19-year-old female G0P0 with no significant past medical history, LMP of 10/9. She has been complaining of vaginal discharge for the past three days. Endorses unprotected sexual encounter 9 days ago with a new male partner. The last sexual encounter with the same male partner was this morning. She states that her sexual partner has been complaining of a “bad smell” coming from her vaginal area. Notes concern for possible STD exposure. Denies h/o STDs, rashes, fever, chills, body aches, abdominal pain, nausea, vomiting, diarrhea, dysuria, hematuria, urinary urgency, urinary frequency, back pain, chest pain, SOB.
Medical history: Denies
OB history: G0P0
Menstrual history: LMP: 10/9/21. Patient states her menses are regular and usually last 5 days. She denies any oligomenorrhea, metrorrhagia.
GYN history: Patient states that she does not use barrier protection, OCPs, or any other contraceptive methods. Denies any history of STIs, fibroids, endometrial polyps, PID, chronic pelvic pain, abnormal pap screens, or GYN cancer
Medical history: Denies any medical history
Surgical history: Denies any past surgical history
Hospitalization: Denies previous hospitalizations
Home meds: Denies any regular medications
Allergies: seasonal allergies, NKDA
Social history: 19 year old hispanic female, catholic, lives at home with parents. She is single and is currently a college student. Denies tobacco, alcohol or any recreational drug use. Denies history of STIs. She is currently sexually active with multiple partners within the past year, and denies use of barrier protection. Denies OCP use.
Family history: Denies any gyn, breast or colon malignancies. Denies family history of CVD, metabolic disease, lung disease, diabetes, thyroid disease, or GI disease.
Review of Systems:
General: patient denies fevers, chills, weakness, unintentional weight loss, night sweats or fatigue.
Head: denies any trauma, headache, dizziness, lightheadedness, loss of consciousness, or changes in balance
Neurologic: denies changes in speech, balance, sensation, numbness, tingling or syncope
Eyes: denies any blurred vision, loss of vision, itching, discharge, photophobia, or swelling
ENT: denies any rhinorrhea, changes in hearing, discharge, vertigo, sneezing, sinus pain, sore throat, swollen lymph nodes, tinnitus or neck pain/stiffness.
Cardiac: denies any chest pain, syncope, diaphoresis, leg edema, heart murmurs, or palpitations
Pulm: denies cough, shortness of breath, dyspnea, pain with inspiration, wheezing or decreased breath sounds
Hematology: denies any easy bleeding or bruising
Skin: denies any lesions, rash, sores, or scars
GI: denies any bowel changes, constipation, diarrhea, abdominal pain, or dysphagia
GU: denies any urgency, frequency, or incomplete voiding, no hematuria, nocturia, or incontinence
Reproductive: Admits to vaginal discharge. Denies vaginal swelling and tenderness, denies any h/o STIs
MSK: denies joint pain or myalgias
Psych: denies anxiety, suicidal thoughts, or depression
Physical exam:
Vitals: BP: 113/67 (left arm sitting), HR: 83, RR: 16, Temp: 98.7 F (oral), O2: 98% on room air, LMP: 10/9
General: 19-year-old female, looks appropriate for age, appears in no acute distress, alert and oriented x 3 to person, place and time, patient is cooperative.
Heart: S1 and S2 present, no murmurs, gallops or rubs. RRR
Lungs: symmetrical breath sounds, clear to auscultation bilaterally, normal chest expansion, no adventitious breath sounds, no wheezes
Abd: No scars or lesions, bowel sounds present in 4 quadrants, soft and nontender to palpation throughout. No guarding, rebound tenderness. – Rovsing’s. – Psoas. – Obturator.
Pelvic exam: performed with chaperone. External genitalia have normal patter. Speculum exam indicates grayish white thin vaginal discharge with fishy odor. – uterine tenderness, no – uterine enlargement. No adnexal masses, no adnexal tenderness
Peripheral vascular: extremities unremarkable, with no palpable cords. No cyanosis. No edema, or signs of DVT.
Neuro: grossly intact to sharp and dull sensation, normal motor function, no movement or gait abnormalities.
Labs:
UA – Neg, no blood, no leukocyte esterases, no nitrates, no ketones, no protein
UCG – neg
Differential Diagnosis:
- Bacterial vaginosis
- Chlamydia/Gonorrhea
- Candida vaginitis
- Vaginal foreign body
Assessment:
JO is a 19 year old female G0P0, with no PMHx, who presents with malodourous greyish white vaginal discharge for 2 days. Patient also notes concern for STD exposure s/p recent unprotected sexual encounter with new male partner 9 days ago, last sexual encounter with same male partner was this morning. Symptoms most likely due Bacterial Vaginosis.
Plan:
- Labs
- Wet Mount, Whiff Test
- STD Testing: Gonorrhea, Chlamydia, Syphilis, HIV, HSV, HepC
- Metronidazole 500 mg PO BID for 7 days
OB/GYN History and Physical 3
Identifying information:
Name: RE
Sex: Female
Age: 24
Date: 10/22/2021
Location: Woodhull Women’s Health Clinic
Source of information: self
Referral: self
Mode of transportation: private vehicle
Chief Complaint: Rash on vaginal area x1 day
History of Present Illness:
RE is a 24-year-old female G0P0 with no significant past medical history, LMP of 10/15. Presents for an irritating and painful rash to genital region since yesterday morning. States that she had an unprotected secual encounter with a new female partner 10 days ago. Denies use of any barrier protection. Denies h/o STDs, fever, chills, body aches, abdominal pain, nausea, vomiting, diarrhea, dysuria, hematuria, urinary urgency, urinary frequency, back pain, chest pain, SOB.
Medical history: Denies
OB history: G0P0
Menstrual history: LMP: 10/15/21. Patient states her menses are regular and usually last 3 days. She denies any oligomenorrhea, metrorrhagia.
GYN history: Patient states that she does not use barrier protection, OCPs, or any other contraceptive methods. Denies any history of STIs, fibroids, endometrial polyps, PID, chronic pelvic pain, abnormal pap screens, or GYN cancer
Medical history: Denies any medical history
Surgical history: Denies any past surgical history
Hospitalization: Denies previous hospitalizations
Home meds: Denies any regular medications
Allergies: seasonal allergies, NKDA
Social history: 24 year old African American female, chrisitian, lives in an apartment. She is sexually active with women and currently works as a Starbucks barista. Denies tobacco, alcohol or any recreational drug use. Denies history of STIs. She is currently sexually active with one partner within the past year, and denies use of barrier protection. Denies OCP use.
Family history: Denies any gyn, breast or colon malignancies. Denies family history of CVD, metabolic disease, lung disease, diabetes, thyroid disease, or GI disease.
Review of Systems:
General: patient denies fevers, chills, weakness, unintentional weight loss, night sweats or fatigue.
Head: denies any trauma, headache, dizziness, lightheadedness, loss of consciousness, or changes in balance
Neurologic: denies changes in speech, balance, sensation, numbness, tingling or syncope
Eyes: denies any blurred vision, loss of vision, itching, discharge, photophobia, or swelling
ENT: denies any rhinorrhea, changes in hearing, discharge, vertigo, sneezing, sinus pain, sore throat, swollen lymph nodes, tinnitus or neck pain/stiffness.
Cardiac: denies any chest pain, syncope, diaphoresis, leg edema, heart murmurs, or palpitations
Pulm: denies cough, shortness of breath, dyspnea, pain with inspiration, wheezing or decreased breath sounds
Hematology: denies any easy bleeding or bruising
Skin: Admits to rash to genital area, denies any sores, or scars
GI: denies any bowel changes, constipation, diarrhea, abdominal pain, or dysphagia
GU: denies any urgency, frequency, or incomplete voiding, no hematuria, nocturia, or incontinence
Reproductive: Denies vaginal swelling and tenderness, denies any discharge or STIs
MSK: denies joint pain or myalgias
Psych: denies anxiety, suicidal thoughts, or depression
Physical exam:
Vitals: BP: 117/74 (left arm sitting), HR: 81, RR: 16, Temp: 98.2 F (oral), O2: 98% on room air, LMP: 10/15
General: 24-year-old female, looks appropriate for age, appears in no acute distress, alert and oriented x 3 to person, place and time, patient is cooperative.
Heart: S1 and S2 present, no murmurs, gallops or rubs. RRR
Lungs: symmetrical breath sounds, clear to auscultation bilaterally, normal chest expansion, no adventitious breath sounds, no wheezes
Abd: No scars or lesions, bowel sounds present in 4 quadrants, soft and nontender to palpation throughout. No guarding, rebound tenderness. – Rovsing’s. – Psoas. – Obturator.
Pelvic exam: performed with chaperone. External genitalia have normal patter. Grouped 2 mm vesicles with associated underlying erythema scattered over the vulva. No inguinal lymphadenopathy. Declined speculum examination. No adnexal masses, no adnexal tenderness
Peripheral vascular: extremities unremarkable, with no palpable cords. No cyanosis. No edema, or signs of DVT.
Neuro: grossly intact to sharp and dull sensation, normal motor function, no movement or gait abnormalities.
Lab
UCG – Neg
Differential Diagnosis:
- Genital herpes simplex virus
- Chancroid
- Chlamydia trachomatis
- Granuloma inguinale
- Human papillomavirus
- Lymphogranuloma venereum
- Neisseria gonorrhoeae
- Trichomonas
- Syphilis
Assessment:
JO is a 24 year old female G0P0, with no PMHx, presents with irritating painful rash to genital area. Patient also notes concern for STD exposure s/p recent unprotected sexual encounter with new female partner 10 days ago. Symptoms most likely due to genital herpes simplex virus.
Plan:
- Labs
- Viral Culture
- STD Testing: Gonorrhea, Chlamydia, Syphilis, HIV, HSV, HepC
- Valacyclovir 1g PO q12hrs x 10 days
OB/GYN History and Physical 3
Identifying information:
Name: RE
Sex: Female
Age: 24
Date: 10/22/2021
Location: Woodhull Women’s Health Clinic
Source of information: self
Referral: self
Mode of transportation: private vehicle
Chief Complaint: Rash on vaginal area x1 day
History of Present Illness:
RE is a 24-year-old female G0P0 with no significant past medical history, LMP of 10/15. Presents for an irritating and painful rash to genital region since yesterday morning. States that she had an unprotected secual encounter with a new female partner 10 days ago. Denies use of any barrier protection. Denies h/o STDs, fever, chills, body aches, abdominal pain, nausea, vomiting, diarrhea, dysuria, hematuria, urinary urgency, urinary frequency, back pain, chest pain, SOB.
Medical history: Denies
OB history: G0P0
Menstrual history: LMP: 10/15/21. Patient states her menses are regular and usually last 3 days. She denies any oligomenorrhea, metrorrhagia.
GYN history: Patient states that she does not use barrier protection, OCPs, or any other contraceptive methods. Denies any history of STIs, fibroids, endometrial polyps, PID, chronic pelvic pain, abnormal pap screens, or GYN cancer
Medical history: Denies any medical history
Surgical history: Denies any past surgical history
Hospitalization: Denies previous hospitalizations
Home meds: Denies any regular medications
Allergies: seasonal allergies, NKDA
Social history: 24 year old African American female, chrisitian, lives in an apartment. She is sexually active with women and currently works as a Starbucks barista. Denies tobacco, alcohol or any recreational drug use. Denies history of STIs. She is currently sexually active with one partner within the past year, and denies use of barrier protection. Denies OCP use.
Family history: Denies any gyn, breast or colon malignancies. Denies family history of CVD, metabolic disease, lung disease, diabetes, thyroid disease, or GI disease.
Review of Systems:
General: patient denies fevers, chills, weakness, unintentional weight loss, night sweats or fatigue.
Head: denies any trauma, headache, dizziness, lightheadedness, loss of consciousness, or changes in balance
Neurologic: denies changes in speech, balance, sensation, numbness, tingling or syncope
Eyes: denies any blurred vision, loss of vision, itching, discharge, photophobia, or swelling
ENT: denies any rhinorrhea, changes in hearing, discharge, vertigo, sneezing, sinus pain, sore throat, swollen lymph nodes, tinnitus or neck pain/stiffness.
Cardiac: denies any chest pain, syncope, diaphoresis, leg edema, heart murmurs, or palpitations
Pulm: denies cough, shortness of breath, dyspnea, pain with inspiration, wheezing or decreased breath sounds
Hematology: denies any easy bleeding or bruising
Skin: Admits to rash to genital area, denies any sores, or scars
GI: denies any bowel changes, constipation, diarrhea, abdominal pain, or dysphagia
GU: denies any urgency, frequency, or incomplete voiding, no hematuria, nocturia, or incontinence
Reproductive: Denies vaginal swelling and tenderness, denies any discharge or STIs
MSK: denies joint pain or myalgias
Psych: denies anxiety, suicidal thoughts, or depression
Physical exam:
Vitals: BP: 117/74 (left arm sitting), HR: 81, RR: 16, Temp: 98.2 F (oral), O2: 98% on room air, LMP: 10/15
General: 24-year-old female, looks appropriate for age, appears in no acute distress, alert and oriented x 3 to person, place and time, patient is cooperative.
Heart: S1 and S2 present, no murmurs, gallops or rubs. RRR
Lungs: symmetrical breath sounds, clear to auscultation bilaterally, normal chest expansion, no adventitious breath sounds, no wheezes
Abd: No scars or lesions, bowel sounds present in 4 quadrants, soft and nontender to palpation throughout. No guarding, rebound tenderness. – Rovsing’s. – Psoas. – Obturator.
Pelvic exam: performed with chaperone. External genitalia have normal patter. Grouped 2 mm vesicles with associated underlying erythema scattered over the vulva. No inguinal lymphadenopathy. Declined speculum examination. No adnexal masses, no adnexal tenderness
Peripheral vascular: extremities unremarkable, with no palpable cords. No cyanosis. No edema, or signs of DVT.
Neuro: grossly intact to sharp and dull sensation, normal motor function, no movement or gait abnormalities.
Lab
UCG – Neg
Differential Diagnosis:
- Genital herpes simplex virus
- Chancroid
- Chlamydia trachomatis
- Granuloma inguinale
- Human papillomavirus
- Lymphogranuloma venereum
- Neisseria gonorrhoeae
- Trichomonas
- Syphilis
Assessment:
JO is a 24 year old female G0P0, with no PMHx, presents with irritating painful rash to genital area. Patient also notes concern for STD exposure s/p recent unprotected sexual encounter with new female partner 10 days ago. Symptoms most likely due to genital herpes simplex virus.
Plan:
- Labs
- Viral Culture
- STD Testing: Gonorrhea, Chlamydia, Syphilis, HIV, HSV, HepC
- Valacyclovir 1g PO q12hrs x 10 days
