History and Physical OB/GYN
Identifying-
Ms. ML, DOB 8/23/94
Interview date- 5/28/18
History from patient
Patient appears reliable
Self- referral
CC- “fever, chills, abdominal pain” x 2 days
HPI- Ms. ML is a 23 year old female, G10101 s/p cesarean on 5/14, presented to the ED complaining of fever, chills, bilateral lower right and left quadrant abdominal pain x 2 days. Patient complains of constant chills and reports fever of 101.6. Patient states that constant chills have prevented her from sleeping. Abdominal pain is described as sharp constant pain, causes her to bend over, rated 9/10, does not radiate, not alleviated by anything, aggravated with movement or palpation. Patient denies constipation or diarrhea; last bowel movement was earlier today, unremarkable. Patient denies chest pain, SOB. Patient denies nausea, vomiting, pain with urination, change in urine color. She denies sexual contact since cesarean, denies history of STIs.
Differential diagnoses-
Endometritis- Patient has recently had c-section, signs and symptoms consistent with infection. Endometritis is a common complication of delivery, however it is usually within a few days not weeks.
Infection from post-op wound- Given that the patient is presenting with signs of infection, fever, chills, abdominal pain, it is possible that the site of the c-section is the source of the infection
PMH-
No significant PMH
PSH-
Cesarean section on 5/14/18 due to prolonged labor
Medications-
“Iron supplements and prenatal multivitamin”
Allergies-
No known allergies
Social history-
Patient denies alcohol use
Patient denies tobacco use
Patient denies illicit drug use
Patient lives with husband and new born
She is no longer working, previously a cashier
Has not been sexually active in “several months”
Family history-
Mother- Alive and well, 47, no known health problems
Father- Alive and well, 48, no known health problems
Brother- Alive and well, 25, no known health problems
Review of Systems-
General-
Patient reports fever, chills, fatigue
Patient denies change in weight
Cardio-
Denies chest pain, sensation of pressure, palpitations, SOB at rest
Respiratory-
Denies SOB at rest or with activity, cough, sputum or wheezing
GI-
Reports bilateral lower right and left quadrant abdominal pain
Denies nausea, vomiting, diarrhea, change in appetite, change in bowel habits
GU-
Denies urinary change in frequency, color, hematuria, or burning with urination
EENT-
Ears- Denies ear pain, hearing loss
Eyes- Denies eye pain, changes in vision, or loss of vision
Nose- Denies rhinorrhea
Throat- Denies throat pain, difficulty swallowing
Neurology-
Denies lightheadedness and dizziness, headaches, loss of consciousness, numbness, tingling
Musculoskeletal-
Patient denies joint pain, muscle pain, back pain
Skin/hair/nails-
Reports skin feeling warm, and some sweatiness at night
Denies rashes, itching, dryness, changes in hair pattern or distribution, nail texture or strength
Lymphatic-
Denies enlargement of lymph nodes
Endocrine-
Denies heat or cold intolerance, polyuria, polydipsia
Psychiatric-
Denies depression, feelings of hopelessness or helplessness, lack of interest in usual activities, anxiety, suicidal ideation
Vitals-
Temp: 102.3 BP: 125/72 Pulse: 98 RR: 17 O2sat: 99% Height: 5’3” Weight: 140
BMI: 24.8
Physical Exam-
General- Patient is lying supine on bed, breathing comfortably, dressed in hospital gown, appropriate hygiene, in no acute distress. Patient is pleasant and responsive and A&O x 3
Cardiovascular- RRR, S1 and S2 heard, no S3 or S4, no murmurs, rubs or gallops
Respiratory- No dyspnea, lungs clear to auscultation bilaterally
Patient is positive for costovertebral angle tenderness on the right side
Neurological-
Mental status- Alert, awake, and oriented
Cranial nerves- 2-12 tested and intact
Motor- Strength 5/5 all extremities bilaterally
Cerebellar- finger to nose good
Reflexes- 2+ at ankles, knees, biceps, and triceps
Sensation- intact to light touch, sharp, dull, proprioception bilaterally
Extremities-No swelling or redness of knees, ankles or feet bilaterally, non tender to palpations. DP, TP, radial pulses 2+ bilaterally. No edema, varicose veins. Extremities are warm, acyanotic
Head- Normocephalic and atraumatic, no facial deformities, masses, lesions, lacerations, abrasions
Abdomen-
Patient has a cesarean section scar that is still covered
Patient is tender to palpation in the lower abdomen bilaterally; she has some guarding
Soft, symmetrical appearing, non-distended, no masses noted. No rebound tenderness, bowel sounds in all four quadrants, tympanic to percussion, no evidence of organomegaly
Pelvic exam-
External- labia, clitoris, urethral orifice & introitus within normal limits
Internal- vaginal mucosa within normal limits, cervix is pink, no abnormal discharge, no foul odor. No cervical motion tenderness.
Bimanual exam- unable to perform properly due to tenderness of patient
Skin-
No signs of jaundice, rashes, masses, abrasions
Mouth-
Oral mucosa is well hydrated, no signs of lesions or masses, non erythema, no tonsilar enlargement
Eyes-
PEERLA, no extraocular movements, palpebral are pink and well hydrated. 20/40 left eye and 20/40 right eye uncorrected, patient wears glasses.
Ears-
Tympanic membranes pearly, grey, no signs of bulging or injection. No discharge or or impaction
Nose/sinuses-
Symmetrical, no rhinorrhea, non-tender, well hydrated mucosa, turbinate inflammation, or frontal/ maxillary tenderness
Lymph nodes-
No facial, cervical, supra/infraclavicular, axillary lymphadenopathy
Rectal exam not preformed
Differential diagnoses-
Pyelonephritis- Patient has signs and symptoms of infection; pyelonephritis may be the source of the infection given that the patient reports CVA tenderness on the right side. However patient does not report any urinary changes or complaints
Endometritis- Patient reports pain over the suprapubic area, she is post op c-section and signs and symptoms are consistent with infection
Tubo-ovarian abscess- there is evidence of cases of tubo-ovarian abscesses that form post cesarean section. The patient is displaying signs of infection and pain in the suprapubic region. Although she has no history of STI, which would be an increased risk factor.
Labs-
CBC:
WBC- 16
RBC- 4.83
HgB- 10.9
HCT- 35.2
MCV- 72.9
Platelets- 323
Neutrophils- 13.7
Urine analysis:
Glucose- negative
Bilirubin- negative
Ketones- negative
Spec Gravity- 1.01
Blood- negative
pH- 6.5
Protein- negative
Nitrite- negative
Leukocyte Esterase- negative
Color- yellow
Character- clear
Assessment-
Patient is a 23 y/o female, G1P1 s/p cesarean section 5/14, presenting with lower abdominal pain, fever, chills x 2 days likely due to endometritis. Given that patient is recently post op cesarean delivery she is at higher risk for endometritis. Although patient reports CVA tenderness, UA was clean making endometritis most likely diagnosis. Blood work shows elevated WBC, 16000. Patient is febrile, 102.3, with elevated heart rate, 98. BP is 125/72, RR is 17 and O2 sat is 99%.
Patient was given ketorolac 15mg inj IVP, acetaminophen 325 mg PO, ceftriaxone 1g IVP, clindamycin 900mg IVP in the ED.
Plan-
- Patient antibiotic regimen changed to ampicillin sodium 1g IVPB, clindamycin 600mg IVPB, gentamicin SO4 IVPB
- Patient given IVF – Lactated ringers 1000 mL
- Patient given Acetaminophen q6h – antipyretic
- Monitor vitals
- Obtain Gonorrhea/Chlamydia cultures
- Blood cultures to be drawn
- Encourage patient to pump breast and dump milk
- Monitor wound
- DVT prophylaxis- encourage ambulation
- Regular diet
- Patient will remain admitted until elevated WBC count, fever, and pain subside
- Patient should follow up in clinic 1 week after discharge
Patient education-
Ms. ML, I understand that you have recently had abdominal pain, fever and chills. It seems as though the cause of you pain is from an infection inside of your uterus. This is a common complication that can take place after a cesarean birth. We have given you antibiotics to kill to bacteria that may be growing that are causing you this infection. You have also been given acetaminophen, which is a pain killer, but will also help bring down your fever. Right now the antibiotics are being given through your IV which will continue until you are discharged. You will probably stay with us in the hospital for 2-3 days depending on how quickly you can recover. We would like for some of your blood work to improve, your fevers to go down and for your pain to go away before we can let you go. So far your cesarean wound looks good, and it is healing well. We will remove the strips today. Additionally, because you are breastfeeding, we will encourage you to pump your breasts and throw out the milk so that you can continue to breastfeed after you leave. Also, when you feel like you are able to get up and walk around it will be beneficial to you to preventing blood clots. Once you are discharged, we would like for you to make a follow up appointment in the clinic in a week.
Endometritis antibiotic.pdf This is an article regarding antibiotics for endometritis
Article summary:
The article I presented corresponded with the H&P regarding a patient with Endometritis. The article pertained to antibiotic regimens for patients with endometritis. It was a Cochrane systematic review that included 42 trials with 4240 patients. It explored the outcomes of different antibiotic regimens to determine what had the best clinical outcome. The results showed that the optimal combination was Intravenous gentamicin and clindamycin. Women treated with this combination experienced better outcomes such as fewer infection in the hospital and shorter stays. Comparitive regimens included cephalosporins, monobactims, penicillins and quinolones, which all had lesser outcomes than IV gentamicin and clindamycin combined. This related to the case I presented as the patient was treated with the same regimen with ampicillin added. It was useful to know that her treatment was shown by this high level study to be an optimal antibiotic treatment for endometritis.
