HISTORY AND PHYSICAL WRITE-UP

HISTORY

Identifying Data:

Full Name: SS

Date of Birth: 11/15/1987

Date: 01/21/2023, 11:00

Source of Information: Self

Reliability: Reliable

Chief Complaint:

“It hurts down here (lower abdomen)”

History of Present Illness:

SS is a 35 YO female G6P1041 at 28 5/7 weeks with PMH of GDM, fibroids, cervical insufficiency w/ cerclage in place, C-section (in 2009, due to non-reassuring fetal tracing), asthma, and migraines who presented with lower abdominal pain on 1/19 just before midnight. Stated that pain and pressure began on 1/18 and has since worsened and described the pain as sharp and 10/10 in severity. Denied radiation of pain or aggravating/alleviating factors. Pt reported poor nutrition/hydration but denied vaginal bleeding or loss of fluid, fever/chills, sick contacts, dysuria, hematuria, frequency, urgency, or N/V/D/C. Pt was given acetaminophen, IV cefazolin, and 2 L IV fluids with no stated improvement in pain. Was unable to tolerate a sterile speculum exam but allowed a digital examination, which showed a closed cervix w/ rescue cerclage in situ and no blood or fluid visible in the vaginal vault. Pt placed on fetal monitoring which showed category I FHR of 145 with moderate variability and the presence of contractions.

1/20, 12:00: Pt started on betamethasone, indomethacin, cephalexin, SCDs, and a diabetic diet with FS/SS for GDMA1. Reassessed that evening and reported significantly improved pain (5/10).

1/21, 00:00: Pt complained of new onset bleeding. SSE was performed and bloody mucus was observed in the vaginal vault. Vaginal exam was 1/80/-2. Cerclage was removed due to concerns of cervical laceration. Pt started on magnesium for neuroprotection and PCN for positive GBS result.

1/21, 11:00: Pt now complaining of worsening pain (10/10) and increased bleeding since cerclage removal. States pain is generalized over entire abdomen and occurs every 5 minutes. Characterizes pain as sharp and denies any aggravating/alleviating factors or radiation of pain. Admits to edema of the feet, nausea w/ vomiting, and right-sided flank pain. Denies weakness/fatigue, fever/chills/night sweats, HA, vertigo, changes in vision, SOB, cough, cyanosis, chest pain, excessive flatulence/eructation, diarrhea, constipation, dysuria, frequency, urgency, or changes in urine color.

Past Medical History:

GDM x 3 days

Abnormal Pap (ASC-US) x 8 days

Cervical insufficiency x 3 months

Fibroid (9 cm x 7 cm) x 4 months

Elevated liver enzymes x 5 months

Migraines x 20 years

Asthma since childhood

Past Surgical History:

C-section, 2009

Medications:

5,000,000 units PCN, single dose, IV infusion

4 g magnesium sulfate, single dose, IV infusion

12 mg betamethasone, two doses, IM

25 mg indomethacin, single dose, PO

2 g cefazolin, single dose, IV infusion

975 mg acetaminophen, single dose, PO

Allergies:

No known allergies

Family History:

Grandmother: alive, hx of breast cancer and diabetes

Social History:

Denies use of tobacco, alcohol, or illicit drugs. Lives with mother. Reports good sleep but minimal exercise. Denies recent travel.

Review of Symptoms:

General: See HPI

Eyes: Denies any visual disturbances, lacrimation, photophobia, pruritis, or corrective lens use.

Cardiovascular: Reports edema over the ankles. Denies any palpitations, hypertension, chest pain, irregular heartbeat, syncope, or known heart murmur.

Pulmonary: See HPI.

Breast: Denies lumps, nipple discharge, or pain.

Gastrointestinal: See HPI.

Genitourinary: See HPI.

PHYSICAL

Vitals:

BP                   119/69

PULSE            92

RESP              19

SpO2               98%

Skin:

Warm and moist, good turgor. Non-icteric, no lesions, no tattoos noted.

Nails:

No clubbing, cap refill <2 secs in upper and lower extremities.

Lungs:

Chest is symmetrical, no deformities, no trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation throughout. Lungs CTAB. Chest expansion symmetrical. No adventitious sounds.

Abdomen:

Gravid abdomen with no asymmetry. No striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no bruits. Pain with palpation in all four quadrants but no guarding or rebound tenderness. Mild right-sided CVA tenderness appreciated.

Lower Extremity:

Bilateral edema noted on ankles/feet. No erythema, ecchymosis, atrophy, or deformities in bilateral upper and lower extremities. Full active range of motion with no crepitus.

Pelvic Exam:

No bleeding from previous cerclage site. Bulging bag noted. Bimanual exam notable for cervical changes to 3/80/0. Previously was 1/80/-2 checked 12 hours prior.

Fetal Heart Tracing:

FHR at 135 bpm w/ moderate variability w/ accelerations and occasional variable decelerations. Currently no uterine contractions.

LABS

Mag                 4.5

Glucose            174

ALK PHOS    320

ALT                 67

AST                  38

GBS                  positive

ASSESSMENT AND PLAN

A: 35 YO G6P1041 w/ hx of GDM, fibroids, cervical insufficiency, C-section, asthma, and migraines admitted for concerns of preterm labor and is s/p cerclage removal due to cervical changes. Pt still complaining of abdominal pain. Pt has mild CVA tenderness and elevated liver enzymes. Uterine contractions have subsided, but FHT shows some variable decelerations.

P: -r/o GU infection pending urine culture results

-monitor for HELLP (has elevated liver enzymes)

-continue fingerstick checks and SS insulin

-continue betamethasone and magnesium

JOURNAL ARTICLE

Vaginal progesterone is as effective as cervical cerclage to prevent preterm birth in women with a singleton gestation, previous spontaneous preterm birth, and a short cervix: updated indirect comparison meta-analysis

• Key Points
  • This was an indirect comparison meta-analysis of 5 clinical trials of 265 women evaluating the efficacy of vaginal progesterone for prevention of preterm birth and 5 clinical trials of 504 women evaluating the efficacy of cerclage. Participants were all preterm single gestation pregnancies with a past history of spontaneous preterm birth and who had cervical lengths less than 25 mm on ultrasound. Results of the meta-analysis showed that there were no statistically significant differences between vaginal progesterone and cerclage for the prevention of preterm birth or adverse perinatal outcomes such as morbidity/mortality, neonatal sepsis, or admission to the NICU. The authors recommended that choice of treatment should depend on patient/physician preference, cost-effectiveness, and possible adverse effects.
• Citation
  • Conde-Agudelo, A., Romero, R., Da Fonseca, E., O’Brien, J. M., Cetingoz, E., Creasy, G. W., Hassan, S. S., Erez, O., Pacora, P., & Nicolaides, K. H. (2018, July). Vaginal progesterone is as effective as cervical cerclage to prevent preterm birth in women with a singleton gestation, previous spontaneous preterm birth, and a short cervix: Updated indirect comparison meta-analysis. American journal of obstetrics and gynecology.
• Hyperlink
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6449041/

SITE EVALUATION PRESENTATION SUMMARY

For my first site evaluation, I presented one History and Physical and five Pharm Cards. I received positive feedback for my pharm card presentation. I wasn’t really sure what should be included on the H&P presentation, so I included the full history, labs, and assessment/plan. I did neglect to include a proper presentation of the patient’s physical exam, and so I was asked to add that and resubmit it.

For the second evaluation, I presented an additional five Pharm Cards, two more H&Ps, and a relevant journal article (seen above).

TYPHON POSTINGS

ROTATION SELF-REFLECTION

I had an overall positive experience at Woodhull. In the clinic portion of my rotation, I think the the most helpful skill I learned was how to do a focused interview appropriate for OB/GYN. Even if I do not end up working in this specialty, I feel like have a much better understanding of what areas will get covered for any patients I refer to OB/GYN, or what care I can expect my patients to receive there if I am part of their primary care team.

I think the most significant knowledge gap I filled in this rotation was the timeline for delivery – for example, distinguishing between Braxton Hicks contractions, prodromal labor, and true labor. Of course I had heard of new moms being in labor for upwards of 20 or even 30 hours, but I didn’t know how much of that was waiting for full cervical dilation and how much was actual pushing.

One thing I struggled with was approaching providers. No one would ask you to do anything, so you had to be really proactive to see any surgeries, deliveries, or procedures. There were times when I hesitated to introduce myself or ask to participate in a procedure because they were busy and then missed out. I have started introducing myself to providers/patients right away rather than wait for a quieter time for fear of being ‘rude,’ and plan to continue doing so in the future.

I also was not able to do injections or venipuncture, but not for lack of trying. I did ask a few people, but was told I should learn those skills on other rotations like IM or the ER.

PICO/CAT TABLE

STUDENT	PICO #1	PICO #2
Axelrod, Emily	In geriatric non ambulatory patients at risk for pressure ulcers, is routine turning of the patient together with dynamic mattresses more effective at prevention than turning with stable mattresses?	In elderly nursing home residents at high risk for falls, does the use of bed alarms help prevent falls in comparison to no intervention?
Bak, Jessica	In a pregnant female with an ovarian cyst and pelvic pain is having a laparoscopy more effective compared to having a laparotomy in terms of blood loss and overall recovery time?	In pregnant females 31 to 34 weeks  gestation is giving betamethasone more effective than giving dexamethasone to mature fetal lungs and decrease respiratory distress syndrome.
Bowers, Abbie	In pediatric patients who are exposed to edible cannabis, does the amount of THC ingested impact the liklihood of needing hospitalization?	In type 2 diabetes, will continuous gluocse monitoring (CGM) improve glycemic control and significantly decrease a1c versus manual blood glucose monitoring?
Chong, Vin Kie	For those with mild-to-moderate COVID-19 infection, does the use of inhaled corticosteroids compared to standard of care alone improve clinical outcomes such as hospitalization, morbidity, or mortality?	In the adult population, can ultrasonography be used as an alternative to computed tomography to safely and accurately diagnose suspected nephrolithiasis?
Exime, Azline	In pediatric patients between ages 1 to 4 with bronchiolitis, does saline, hypertonic saline or bronchodilator nebulizer treatments help improve symptoms more with less side effects?	In children with Wilson’s disease is Zinc or Penicillamine a more effective treatment in decreasing/improving symptoms?
Fakir, Heba	In patients admitted for Central DI, how does the usage of Vasopressin compared to Desmopressin affect outcomes like side effects or efficacy of treatment?	In patients admitted for Acute Pancreatitis, how does using Insulin for treatment affect outcomes like the efficacy of treatment?
Godoy, Mackenzie	Can the use of CBD as an adjunct to antipsychotic medications improve the treatment of positive symptoms of schizophrenia by reducing the level of positive symptoms?	Does the addition of curcumin supplementation reduce relapse rates in adults >/= 18 diagnosed with IBD vs standard therapy alone?
Grant, Nia	In a patient with a minor finger laceration, does a digital block or local anesthesia provide better pain management during repair?	In patients with moderate to severe allergic rhinitis, does an oral antihistamine/intranasal corticosteroid combination or intranasal antihistamine/intranasal corticosteroid combination provide better symptomatic relief?
Hussaini, Immadullah	In a febrile infant (0-21 days old), does giving empiric acyclovir  lead to better outcomes compared to waiting for HSV results?	In children that present with acute appendicitis, can antibiotics be used as treatment instead of an appendectomy?
Ishmael, Akram	In women with yeast infections, does yogurt result in similar or increased cure rates compared to antifungals?	In women with labor pain, is acetaminophen a superior method of pain management compared to opioids?
Jacobs, Lily	Among alcoholic adults (P), how does the impact of brief interventions (I) vs no interventions (C) help decrease the risk for traumatic injuries (O) in the ED?	Among adults who present wiith thermal burns (P), how effective is active cooling with water as a first aid measure (I) vs no intervention (C) in improving wound healing and decrease in complications? (O)
Kaur, Navneet	In adults with osteoarthritis, does using only turmeric extract, in contrast to NSAIDs, improve joint pain and function?	In adult patients with hyperlipidemia, does taking CoQ10 supplementation decrease the likelihood of statin-associated myopathy compared to the placebo/no intervention?
Kwong, Jennifer	In middle aged patients with MDD (Major Depressive Disorder), how does exercise compare to pharmacologic interventions (such as antidepressants) in terms of reducing or eradicating depression?	In adult males who are diagnosed with schizophrenia and experience weight gain from olanzapine, does the addition of metformin result in increased weight loss when compared to just physical activity or decreased caloric intake?
Lam, Tiffany	In postmenopausal osteoporosis, is bisphosphonate therapy more effective in increasing bone density than monoclonal antibody therapy?	In adult patients, how effective is topical capsaicin in reducing diabetic neuropathic pain?
Lerebours, Nicole	During peak occupancy in Emergency Departments, does the activation of over-flow units reduce provider burn out and improve patient outcomes?	In patients with perirectal/perianal abscesses, does wound packing vs. no wound packing after I&D impact rates of healing and perceived pain levels?
Levine, Robert	Is the DASH diet more effective than Amlodipine at reducing blood pressure in treatment naive hypertensive adults?	Is varenicline more effective than bupropion at smoking cessation in adult cigarette smokers?
Martinez, Rafael	In comparison to metformin, can intermittent fasting serve as an effective way of decreasing insulin resistance among the pre-diabetic or at-risk population	In a patient with stable cardiac disease, does exercise and lifestyle modifications fair better than invasive interventions, in terms of morbidity and mortality.
McNussen, Amanda	Are asthmatic patients who are treated for cough related to upper respiratory infection, compared to no intervention, less likely to progress to an acute asthma attack?	Does immediate mother & baby skin-to-skin contact lead to less morbidity and mortality in premature neonates compared to placing the infant in an isolette incubator immediately after birth?
Newmark, Stevie	Does using a high blood pressure treatment plan shared decision making tool to educate adults with elevated blood pressure (>140/90) in an urgent care setting improve future blood pressure readings compared with no intervention?	In patients with lacerations, how does primary closure compared to delayed or no closure affect wound healing and infection rates?
Pinsky, Shaindel	In patients with dysphagia and lack of appetite secondary to advanced dementia, does careful hand feedings by a caregiver in comparison to nasogastric or PEG tube feedings prolong the life of a patient with an otherwise poor prognosis?	In older adults residing in a rehab facility who are suffering from delirium, does giving melatonin in comparison to no intervention help reduce agitation and other delirium symptoms?
Rogers, Amanda	When detecting respiratory pathogens, are nasal swabs more effective/accurate than nasal aspirate?	In pediatric patients, does the use of distraction techniques during vaccine administration or phlebotomy result in lower pain scores when compared to no intervention?
Shah, Siddharth	In patients with esophageal varices, is band ligation superior to sclerotherapy?	Patients who have suffered from a stroke. Can exoskeleton help patient regain movement, and GAIT?
Simon, Andrew	Does a vasectomy increase the risk of developing genital cancer?	Do aerobic activity exercises improve cognitive function in Alzheimer patients?
Tekalign, Isaiah	Is colonoscopy paired with fecal occult blood testing more efficient in identifying colon cancer compared to colonoscopy alone in adults over the age of 45?	When treating an adult stroke patient is acupuncture efficacious in improving mobility versus not receiving acupuncture?
Winter, Hannah	In the setting of acquired umbilical hernias with a defect of 2 cm or larger for adults older/equal to age 30, does the use of a mesh during an open hernia repair greatly reduce the risk of recurrence?	Does chewing gum reduce the chance of ileus postoperatively for adult surgical patients undergoing gastrointestinal surgery?
Yeasmin, Tamanna	Do pediatrics patients with hypertrophic turbinates have a better quality of life with inferior turbinate reduction surgery versus no surgery?	In elderly bariatric patients, does a Sleeve Gastrectomy provide more weight loss and less post-op complications than a Roux-en-Y Gastric Bypass?