Name: Christy R.
MRN: 123456
DOB: 12/01/1992
Age: 19
CC: Rectal Bleeding, abdominal pain and vaginal discharge
Subjective:
Pt is a 19 year old female, G0P0000, who presents to the ED for rectal bleeding during defecation for the
past two days. She states that two days ago she noticed bright??red blood in the toilet following her
bowel movement. Pt describes blood as bright red, not clotted and separate from her stool. She denies
ever experiencing similar episodes. She is also experiencing some abdominal pain, primarily in the
suprapubic region and a small amount of vaginal discharge for the past week, which is primarily red in
color. She states that the abdominal pain has occurred on and off for the past two months and is
“crampy” in nature. She does experience some relief with use of a heating pad and rest, but notes the
pain is worse when she is moving around at work.does it wake her at nite? Notably, Pt visited the ED
one month ago for her abdominal pain and was diagnosed with PID at that time. She was prescribed
doxycycline, however she discontinued the medication after one week because “it was upsetting her
stomach”. Since her last visit to the ED she has not seen her PCP or OB-GYN. Her abdominal pain is a
7/10, with a 10 being the abdominal pain she first experienced two months ago. Pt denies taking any
medications for her abdominal pain. Pt’s LMP was two weeks ago, which she describes as being five
days long and “regular”. Pt experienced menarche at age 13 and states that her cycles are typically
about 21-28 days apart and last 5-7 days. Pt states that she occasionally has heavy periods and that she
was previously placed on oral birth control, Ortho Tri-Cyclen, which did lessen her bleeding and
cramping. However, she has not been on OCPs in over a year.
Pt denies being pregnant and states that she has been in a monogamous relationship for the past three
months with her female partner. Is she using condomsnow?Prior to this relationship Pt states she was
in a monogamous relationship with a male for approximately 9 months, during which period she used
condoms for birth control. Pt denies any itching or burning with urination. Pt states that she was
diagnosed with Chlamydia at her ED visit last month, but has no other history of STDs. Denies history of
ovarian cysts, endometriosis or uterine fibroids. Denies nausea, vomiting, diarrhea, constipation, fevers,
and chills.
Family Hx: Past family history is significant for cardiovascular disease in her mother and hypertension in
her father. Denies family history of endometriosis, breast cancer, ovarian cancer, cervical cancer,
diabetes mellitus, and blood/clotting disorders.
Social Hx: Pt is employed at local gas station and lives with her girlfriend. Pt states that she smokes 1
PPD for the past 2 years. Occasionally drinks alcohol, approximately 4-5 drinks a month. Oz.’s of what?
Denies use of illicit substances.
Allergies: NKDA
Immunizations: Current
Medications: Sertraline 50mg PO daily
PMH: Depressionx duration, PID
PSH: Tonsillectomy (1999)
Objective:
Vitals: Temp: 99.7F HR: 88 RR: 20 BP: 138/70 Weight: 110 lbs. Height: 60 inches BMI: 21.5
General: Mildly anxious, resting on exam table; A&O x3; Well groomed, pleasant affect
Neck: Supple, trachea midline; No carotid bruits, no thyromegaly, no lymphadenopathy of occipital,
posterior or anterior cervical chainsrest of nodes????
Breasts: Nontender; No skin dimpling or buckling; No nipple inversion, discharge or asymmetry; No
breast masses or lesions; No supraclavicular or axillary lymphadenopathy.
Lungs: No scars, ecchymosis, asymmetry of chest noted; Non-labored breathing, no accessory muscle
use or intercostal retractions; CTA bilaterally, no wheezing/rales/rhonchi/stridor
Heart: R/R/R; No murmur/rubs/gallops; No peripheral edema
Skin: Warm, pink, dry; No pallor, cyanosis, rashes or bleeding
Abdomen: Non-distended; No scars, lesions or striae; No bruits noted; Normoactive BS x4; Soft;
Tenderness noted in suprapubic region; No guarding or rebound tenderness
Pelvic: External genitalia without adhesions or lesions; Small amount of mixture of mucopurulent and
bloodcolor?noted in vagina; Vagina is rugated, pink, no lesions visualized; Cervix erythematous, os nonpatent, non-friable. Positive cervical motion tenderness; Uterus anteverted, firm, mobile, mildly tender;
Adnexa non-palpable and non-tender.
Rectal: (As performed by preceptor) Sphincter tone appropriate; No masses, fissures and hemorrhoids;
Stool for occult blood negative
Labs/Tests:
Quantitative hCG: Negative
CBC:
WBC
12.1
(RR 4.0-11.1)
RBC
4.67
(RR 4.18-5.64)
Hemoglobin
12.5
(RR 12.1-16.3)
Hematocrit
35.2
(RR 35.7-46.7)
MCV
95.9
(RR 80.0-100.0)
MCH
33.3
(RR 27.5-35.1)
MCHC
34.8
(RR 32.0-36.0)
Platelets
156
(RR 150-400)
Cultures: pending cx of/for what??
UA: negative for WBCs, protein, blood, bacteria and glucose
ESR: 36 mm/hr
Assessment:
1) Pelvic Inflammatory Disease
2) Tobacco Cessation
3) ETOH???she is only 19!
Differential Diagnosis: Appendicitis, Urinary Tract Infection, Endometriosis
Orders:
Rocephin, 250mg IM in the ED
Zithromax, 1g PO in the ED
Norco, 5/325mg, 1 tablet PO q 4-6 hours PRN for pain, Disp: 20
Plan:
1) Pelvic Inflammatory Disease: In combination with previous non-compliance of antibiotic
regimen and Pt’s exam and lab findings, she appears to still be suffering from PID. Pt given
Rocephin, 250mg IM, and Zithromax, 1g PO, in the ED secondary to previous noncompliance. She was advised to watch for adverse reactions to the antibiotics including
difficulties breathing, swelling, and hives. If she experiences any of these reactions, Pt was
instructed to obtain medical care immediately. What about side effects of Norco
Based on Pt’s description of her rectal bleeding and her stool being negative for occult
blood, the source of her bleeding may be from a vaginal rather than rectal source. Pt
strongly encouraged to schedule follow up appointment with OB-GYN for further evaluation
within the next week. Discussed with Pt the possible complications her PID could have if not
treated properly and resolved, including increased risk of infertility and ectopic
pregnancy.what about her education on exactly what PID is???
If her rectal bleeding continues or worsens, Pt was encouraged to contact her PCP or return
to the ED for further evaluation. Also discussed with Pt the possibility that her partner
might have an STD and should consider going to her PCP for testing and treatment if
indicated.
2) Tobacco Cessation: At this time Pt declined information on tobacco cessation. The risks
associated with tobacco use, including the increased risk of certain cancers and COPD, were
discussed and Pt stated that she would try to “cut back”. Also encouraged Pt to discuss
smoking cessation with her PCP. And etoh!
Furthermore, Pt states that she is due for an annual physical examination with her PCP. Pt was given
paper copies of her lab work from her visit to take with her for her PCP. Pt agreed to schedule
appointments with her PCP and OB-GYN within the next week. Pt advised to watch for a worsening of
her bleeding and to return to the ED if her condition worsens. Pt agreed to plan.
Vanessa G Wittstruck, PA-S
25/30
11/28/12
22:13