Identifying Data:

Age: 30 y/o

Sex: female

Date of encounter: October 24, 2022

Location: Women’s Health Clinic – Queens Hospital Center

Race: Hispanic

Source of Information: Self via official Spanish interpreter

Reliability: Reliable

Source of Referral: Self

 

Chief Complaint: Initial obstetric visit, new pregnancy

 

History of Present Illness:

Pt is a 30-year-old Spanish speaking female, G3P2001, with 2 previous C-sections, at 8 weeks 3 days gestation (estimated by sono), presenting to the clinic for initial obstetric visit. The patient currently has no complaints. She denies vaginal fluid leakage, vaginal bleeding, abdominal pain, dysuria, hematuria, headache, visual changes, or dizziness. Pt mentions wanting to have bilateral tubal ligation during C-section for this pregnancy.

Of note, current pregnancy occurred after IUD displacement. Pt was seen at QHC ED on 10/06/22 for mild right sided abdominal pain and 2 positive pregnancy tests at home taken after missed period (LMP 08/14/2022). Paragard IUD was put in place in April 2022 at an outside facility. In the ED, a transvaginal US was done which revealed a single live IUP at about 5 weeks 6 days gestation, and an IUD located in the lower uterine segment/cervix. Her BHCG was 15,274 mlU/mL. Pt stated this was an unexpected but desired pregnancy. At that time, GYN was consulted, and IUD was removed at bedside without any complications.

 

LMP: 08/14/2022

Prior to pregnancy, menses were regular (every 28 days), last 6 days.

Estimated date of delivery: June 02, 2023

 

Obstetric History:

2008 – C-section at 39 weeks in Honduras (indication: elective/MD choice, as per pt). Male. No complications. Birth weight unknown.

2015 – C-section at 39 weeks in Honduras (indication: repeat). Male. No delivery complications, but child passed at 1 year age due to chickenpox infection. Birth weight unknown.

**unable to receive operative notes from Honduras**

 

Past Medical History:

Nephrolithiasis, right sided – 2020

Chlamydia – 2019 (successfully treated)

Last pap: 04/21/2022 – Negative

 

Immunizations – up to date

 

Past Surgical History:

Cesarean section x2 – 2008, 2015

Laser lithotripsy and right ureteral stent placement – 2020

 

Medications:

Prenatal vitamins, 1 tablet PO daily

Folic acid 1mg tablet PO daily

 

Allergies:

(+) Seafood allergy (reaction: nausea, vomiting, headache).

Otherwise, denies any drug or environmental allergies.

 

Family History:

Maternal grandmother with type 2 diabetes mellitus.

Otherwise, denies heart disease or cancer history in family.

 

Social History:

Patient is married and lives with her husband and 14 y/o son. She is able to complete ADLs and iADLs independently. States she desires this pregnancy and has enough financial and social support at home.

 

Sexual activity – sexually active with husband only.

Habits –Denies smoking history. Denies alcohol use. Denies history of illicit substance use.

Sleep – No complaints.

Travel – No recent travel.

 

Review of Systems:

General – Denies recent fever, chills, weight loss/gain, fatigue, sweats, or change in appetite.

Skin/nails –Denies rash, change in pigmentation.

Head – Denies headache, dizziness, lightheadedness, recent head trauma.

Eyes – Denies visual disturbances.

Nose – Denies congestion, rhinorrhea.

Mouth/throat – Denies sore throat, difficulty swallowing.

Neck – Denies pain, stiffness.

Pulmonary – Denies SOB, DOE, cough, wheezing, orthopnea.

Cardiovascular – Denies chest pain, palpitations, lower extremity swelling, syncope.

GI – Denies abdominal pain/contractions, nausea, vomiting, diarrhea, constipation, blood in stool, change in stool color. No recent changes in BM.

Obstetric/Genitourinary –  Denies vaginal leakage, abnormal vaginal discharge, vaginal bleeding, dark urine, incontinence, urgency, dysuria, hematuria, frequency.

Nervous – Denies tingling, seizures, confusion, weakness, numbness, gait change.

Musculoskeletal – Denies back pain, body aches.

 

 

Physical Exam:

Vital signs:      BP: Seated              R-arm: 116/74

RR:  18 breaths/min, unlabored

Pulse: 74 bpm, regular

T:  98.2 degrees F (oral)

O2 Sat: 98% on room air

Height:  5 ft  1 inches        Weight:  150 lbs.       BMI: 28.34

 

General: Pt alert, oriented. Appears comfortable, no acute distress. Cooperative. Well nourished. Looks stated age. Well groomed.

Skin: No diaphoresis. Skin is warm. No ecchymosis. Nonicteric, no other lesions noted. No tattoos, rashes or discoloration appreciated throughout.

Hair:  Appropriate distribution. No female pattern baldness.

Nails:  no clubbing, capillary refill <2 seconds in upper and lower extremities.

Head:   normocephalic, atraumatic

Ear: Symmetrical and appropriate in size.  No lesions, masses, trauma on external ears. No hearing aid.

Nose – Symmetrical. No masses, lesions, deformities, trauma, discharge.

Nasal mucosa pink & well hydrated. No discharge noted.

Mouth/Oropharynx – Lips appear pink and moist, with no masses, cyanosis, or ulcers. Mucosa pink and moist. No lesions or masses. No leukoplakia. Palate pink, moist, intact with no lesions, masses, or scars.

No gingival hyperplasia or recession.

Tongue is midline. No discharge, masses or lesions.

Uvula is midline and rises symmetrically with phonation. No edema or lesions.

Oropharynx is pink and moist. Tonsils are symmetric and without hypertrophy. No swelling, erythema, exudates, masses/lesions, foreign bodies.

Neck – Supple. Non-tender to palpation. Trachea is midline. No masses or lesions. Lymph nodes non-palpable bilaterally. No stridor. 2+ carotid pulses bilaterally. No cervical adenopathy noted. No thyroid enlargement, nodules, or tenderness appreciated.

Eyes – Eyelids without lesions, edema, or discharge. No strabismus, exophthalmos or ptosis.  Sclera white, conjunctiva pink bilaterally.

Chest/Pulmonary: Chest is symmetrical, without deformities or trauma. Lat to PA diameter is 2:1. Respirations unlabored. No use of accessory muscles noted. Chest nontender to palpation throughout. Lungs CTA bilaterally. No wheezes, rhonchi, rales, or other adventitious sounds.

Breast: Symmetric. No dimpling, no masses to palpation. Nipples are symmetric without discharge or lesions. No axillary nodes palpable.

Heart: Regular rate and rhythm. Distinct S1 and S2. No murmurs, S3, S4, friction rubs, or splitting of S2 appreciated. Carotid pulses are 2+ bilaterally without bruits.

Abdomen: (+)well healed vertical midline scar under umbilicus, measuring about 11cm. No guarding or rebound. Abdomen nontender to palpation. No hepatosplenomegaly. Abdomen is symmetric. No striae or pulsations noted. Bowel sounds normoactive in all 4 quadrants. No CVA tenderness noted.

Pelvic exam: External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix slightly pale/bluish in color, without lesions or discharge. Cervical os is closed. No pooling of fluid in the vagina. No blood. No cervical motion tenderness. ***Endocervical swab was obtained during exam***

Mental Status Exam: Appearance and behavior – patient alert, no abnormal movements, grooming/hygiene appropriate, appropriate facial expression and manner.

Speech and language – follows 3 stage commands. Speech is of appropriate quantity, rate, volume, flow, and articulation.

Oriented to name, date, time, location.

Neurologic:

Cranial Nerves –See “Eyes” for CN II assessment. Conjugate gaze without nystagmus. No ptosis. Symmetric and fluid facial movements. No difficulty with BMP speech sounds.

Soft palate rises and uvula remains midline. No hoarseness or nasal quality in voice. No facial droop. No difficulty with LTND speech sounds.

Peripheral Neuro –

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. Gait steady with no ataxia.

Musculoskeletal: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM (Full Range of Motion) of all upper and lower extremities bilaterally.

 

 

BEDSIDE ULTRASOUND:

+IUP at about 8 weeks 0 days, +Fetal heart

 

Differential Diagnoses:

• Pregnancy after failed IUD

Assessment/Plan:  30 y/o female, G3P2001, presenting to the clinic for initial obstetric visit at 8 weeks 3 days estimated gestation after failed IUD and removal. Pregnancy is desired. No complaints at this time. Plan for official US and labs (UA, urine culture, GC/Chlamydia, CBC, Type and screen, HIV, quantiferon, hep B). Return to clinic in 3 weeks.

Advised pt to go to the ED if she experiences symptoms including vaginal leading/leakage of fluid, abdominal pain/contractions, or any other concerns.