Resident:
Attending:
CC: Abdominal cramps and back pain.
HPI: 20-year-old G1P0 at 39 wks by LMP and Ultrasound at 14 weeks comes in complaining of back pain and abdominal cramps. She is on day two of Macrobid treatment for UTI. She has been having this pain for a few weeks now but intensified and she wanted to have it checked.
The patient is feeling fetal movements as usual.
Prenatal Care: Obstetrician is Dr. xyz and the patient says she has been seeing her since 10 weeks and has gotten all tests and ultrasounds done on time. But the results are not available now.
REVIEW OF SYSTEMS:
Positive Review of Symptoms mentioned and elaborated on in HPI.
Head: Denies H/A, trauma, loss of consciousness.
Eyes: Denies visual loss, diplopia.
Ears: Denies: deafness, tinnitus, discharge, pain
Nose: Denies discharge, obstruction, epistaxis
Mouth: Denies any sores, gingival bleeding, jaw pain
Neck: Denies stiffness, issues swallowing.
Respiratory: Denies cough or SOB.
Cardiovascular: Denies Chest pain or palpitations.
Gastrointestinal: Denies melena, abd pain, n/v/d
Genitourinary: Denies dysuria, discharge.
Skin: Denies: lesions, rashes, pruritis.
Musculoskeletal: Denies joint pain, swelling or increased warmth.
Neuro: Denies numbness, tingling, weakness.
Psyc: Denies feelings of anxiety and depression at this time.
PGynHx: No abnormal paps; currently with UTI treated with Macrobid; IVF; stage IV endometriosis.
PMH: Anxiety. No DM, HTN, Asthma, thyroid disorder or seizures.
PSH: None
FH: None pertinent
SH: No tobacco, alcohol or drug use, married, no domestic violence.
Meds: Prenatal vitamins, Macrobid
Allergies: NKDA
MEDICATIONS:
escitalopram
nitrofurantoin: 100 mg,1 cap,Oral,BID
Allergies: NKDA
Prenatal labs: Results requested from office.
PHYSICAL EXAMINATION: 127/68; 92; Oxygen sats 100% RA; RR 18; T 36.9
General: NAD, well-developed, well-nourished. Cooperative.
Psychiatric: AOX3
HEENT: NC / AT, PERRL, EOMI, Conjunctivae are pink and anicteric. normal dentition, normal mucous membranes, oral mucosa well hydrated.
CV: Normal S1 S2, RRR. No M/R/G, heaves, or thrills. The chest is non-tender to palpation. No JVD, no edema, warm, well-perfused, + 2 DP / PT pulses.
Respiratory: CTAB, no W/R/R, no use of accessory muscles of respiration.
GI: Gravid, Soft NT. No guarding or rebound tenderness.
Skin: No rashes or lesions
Musculoskeletal: FROM, no synovitis
Neurologic: No focal neurologic deficits.
Extremity: No edema. NT; Normal DTRs.
+Fetal fibronectin. External os is closed per nurse exam.
No contractions on Toco. FHT reactive.
ASSESSMENT & PLAN:
20 yo G1P0 at 39 weeks
Abdominal pain and low back pain in the context of possible UTI
Plan:
CBC, Type and Screen.
Betamethasone x 2 doses. The first dose has been administered.
#Code Status: Full Code
Patient verbalized understanding of the implications of his decision.
Resident Statement: The attending physician personally examined and thoroughly discussed and directed the plan of care for this patient.
Kenneth Acha, MD
Family Medicine PGY2 Resident
University of California in Riverside