History and Physical from Rotation #5 OB/GYN

History and Physical from Rotation #5 OB/GYN

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.

Image result for endometritis

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Endometritis antibiotic.pdf  This is an article regarding antibiotics for endometritis

Article summary:

Endometritis antibiotic.pdf

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.

 

 

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