Admission Note for Pelvic Pain, PID, GU Sx

DATE:

CHIEF COMPLAINT: Pelvic pain

HISTORY OF PRESENT ILLNESS:

Site-
Onset-
Character-
Radiation-
Alleviating factors-
Time course-
Exacerbating factors-
Severity-
Similar pain before-
Nausea-
Vomiting-
Diarrhea-
Constipation-
Loss of appetite-
Black/bloody stools-
Home pregancy test-
Vulvar/vaginal pain-
Low back pain-Flank pain-

Vaginal discharge- , Vaginal bleeding- , Passing clots/tissue-
LMP-Missed periods- , Irregular periods-
Post-menopausal-

Fever/chills- , SOB- , CP- , Headache-
Dysuria- , Blood in urine- , Frequent urination-

Obstetric Hx-> GPAb
Sexual hx-> active
Contraception-

ER Tx given-

PAST MEDICAL HISTORY (positives are circled):
PID STD Ectopic pregancy Ovarian cysts Endometriosis
PUD Gallstones Kidney stones UTIs MI CAD HTN DM
Stroke CA PVD DVT COPD Asthma

EGD Colonoscopy

PAST SURGICAL HISTORY (positives are circled):
Tubal ligation C-section
Cholecystectomy Hernia Appendectomy Hysterectomy

MEDICATIONS:

ALLERGY: NKDA

FMH (positives are circled):
CAD<> 55 yo DM Stroke HTN CA

SOCIAL HISTORY: Independent NH Lives w spouse son daughter
Alcohol- no heavy occasional last drink
Smoker- no
Illicit drugs- no cocaine heroin marijuana

REVIEW OF SYSTEMS (positives are circled):


PHYSICAL EXAM:

VITALS:

GENERAL APPEARANCE: WD/WN in NAD
SKIN: no rash
HEENT: NC/AT, PERRLA (B), moist MM, no epistaxis
NECK: Supple, no JVD
LUNGS: CTA (B)
HEART: Clear S1S2, RRR
ABDOMEN: Soft, NT, ND, +BS
Pelvic exam:
Rectal exam:
EXTREMITIES: no edema
PERIPHERAL VASCULAR: palpable
NEURO:
AAO x 3
CN 2-12: non focal
MUSCLE STRENGHT: 5/5 (B)
DTR: ++DTR
SENSATION: non focal
CEREBELLAR: non focal

LABS:

Amylase , Lipase
UA-
hCG- , Gonococcus- , Trichomonas- , Chlamydia-
CXR:
KUB:
EKG:

ASSESSMENT:
-Abdominal pain due to
PID
Herpes genitalis
Ovarian cyst
Gastroenteritis
Gastritis
PUD
Pancreatitis
Cholecystitis
Diverticulitis
UTI

PLAN:
-IVF
-EKG now and in AM
-UA
-MS 2 mg IV q 2-4 hr PRN pain

Signature:


Created: 2/2005
Updated: 03/08/2007