OB H&P 3

CHIEF COMPLAINT:

  • “Right lower stomach pain and vomiting x 2 days.”

HISTORY OF PRESENT ILLNESS:

44 year old with a pmhx HIV, hypertension, asthma of presenting  to the ER for RLQ abdominal pain associated with vomiting for 2 days.  Patient describes the pain as sharp and localized to her right lower quadrant and states it has been constant since onset. Patient states she took OTC tylenol for pain with no relief of symptoms. Patient states episodes of vomiting occur simultaneously with the onset of pain. Patiente states the color of vomit is whatever she had eaten that day and states she has not had an appetite since pain started. Patient states pain is 10/10 and currently denies any other significant symptoms. 

Patient is HD#2 admitted for pelvic pain/TOA(ovoid complex cystic structure seen in right adnexa measuring approximately 7.6cm  x5.4 cm x 7.5 cm). Patient was sitting in bed comfortably, complaining of feeling a bit constipated.Patient is on a regular diet and states her last BM was 2 days ago.Patient has been voiding and ambulating otherwise without difficulty.Denies any dizziness, nausea/vomiting or abdominal pain currently.    

MEDICAL HISTORY:

  • Medications:
    • Tenofovir 50-200-25 MG tablet
    • Losartan 100 mg tablet
    • Spiriva respimat 1.25 mcg/act 2 puffs daily.
  • Medical History:
    • Asthma
    • HIV
    • Hypertension
    • Abnormal PAP smear of cervix
  • Surgical History:
    • Ovarian cyst drainage- 2022
    • PR Laparoscopy with removal of adnexal structures. 
  • Allergies:
    • Penicillin
    • States she took Amoxicillin with no reaction.

FAMILY HISTORY:

  • Mother: Deceased, hx of alcohol abuse
  • Father: Alive & well, hx of hypertension

SOCIAL HISTORY:

  • Smoking: Everyday( 0.4 packs/day)
  • Alcohol: Drinks weekly(1 glass of wine, 1 drink containing 0.5 oz of alcohol)
  • Illicit Drug Use: Denies
  • Occupation: Unemployed
  • Caffeine: Denies
  • Marital Status: Single, 
  • Exercise: Denies any exercise

GYN HISTORY:

  • Last PAP smear 12/23, results abnormal(LSIL)
  • OB cycle: Having periods 
  • Sexually active with multiple partners, uses protection

REVIEW OF SYSTEMS:

  • General: Denies recent weight loss or gain, fever, or fatigue.
  • Skin: Denies rashes or lesions.
  • Breast: Denies lumps, tenderness, or discharge.
  • Cardiac: Denies chest pain, palpitations, or syncope.
  • Pulmonary: Denies cough, wheezing, or shortness of breath.
  • Gastrointestinal:Admits to constipation 
  • Genitourinary: Denies dysuria, hematuria, or increased urinary frequency.
  • Musculoskeletal: Denies joint pain or muscle weakness.

PHYSICAL EXAM:

  • General: Alert and oriented and cooperative during exam 
  • Vitals:
    • BP: 105/63 mmHg
    • Pulse: 98 bpm
    • Temp: 100.8°F
    • Wt: 215 lbs
    • Spo2:97%
  • Skin: No rashes or lesions.
  • Breast: Symmetric, no masses, no axillary lymphadenopathy.
  • Cardiac: Regular rate and rhythm, no murmurs, gallops, or rubs.
  • Lungs: Clear to auscultation bilaterally, no wheezes or crackles.
  • Abdomen: Soft, non distended, tender on deep palpation. .

ASSESSMENT:

  • 44 y/o G1PO HD#2 for possible TOA, currently admitted for further evaluation and continuation of care

PLAN:

  • TOA
    • Continue antibiotics(Change regimen to Ceftriaxone/doxy/flagyl)
    • Radiology contracted for possible IR drainage tomorrow
  • HIV
    • Last CD4 count 664
      • Continue to take Biktarvy.
  • DVT prophylaxis
    • Currently on lovenox
  • Abnormal PAP
    • LSIL HPV + 12/2023(missed follow up appointment)
      • Reschedule appointment for colposcopy.
  • Anal Pap
    • Arrange an appointment for anal colposcopy.
  • Constipation 
    • Start Bisacodyl 10mg