Pt is a young female who came in with complaints of right lower abdominal pain since 7 am this morning, She got up from bed and suddenly felt a sharp constant pain. She is also experiencing nausea and vomiting, She describes the abdominal pain as a 5/10. Pt is 6 weeks pregnant, G2 P1. She mentioned she went to her OB 6 weeks ago, she was diagnosed with a yeast infection and was given Monistat to treat the infection. She is having some vaginal discharge along with her infection. Denies recent surgeries, fever, chills, SOB, chest pain, dysuria, hematuria, bowel/ Urine incontinence, abnormal gait, vaginal bleeding, and cough.
CC: Abdominal Pain HPI: The patient is a __-year-old woman who is 6 weeks pregnant and presenting today with constant abdominal pain. She experienced a sudden onset of sharp and constant pain in the right lower quadrant when she got up this morning at 7 am. She rates the severity of the pain as 5 out of 10. The patient denies taking any medication for the pain. The patient mentions a recent visit to her obstetrician, who prescribed Monistat for a yeast infection, but the medication did not relieve her abdominal pain. She denies taking any other medications and has no history of medical problems related to her abdomen or any surgeries. This is her second pregnancy, with her first child being 3 years old. The patient denies having a fever but reports experiencing nausea and has vomited twice. The patient denies changes in her bowels, symptoms of urinary frequency, urgency, or burning. The patient confirms that the pain does not spread to other areas and remains localized in the right lower quadrant. The patient denies taking Tylenol. She denies loc, cp, sob, leg pain/swelling, and rash.
CHIEF COMPLAINT: Abdominal pain HPI This six-week pregnant patient came to the clinic with complaints of abdominal pain in the right lower quadrant. The patient claims she woke up at 7 o’clock this morning when she felt a sharp, sudden pain on her side, she describes the pain as consistent and rated it as 5/10 on the pain scale. She visited her OB yesterday due to vaginal discharge and reveals that she is positive for Yeast infection and Monistat was prescribed. She reported that she felt nauseous and vomited (2x). She denies having a fever, headache, presence of some rashes, and changes in bowel movement. She also reports that there are no unusual symptoms such as vaginal bleeding, shortness of breath, and chest pain. She denies any previous surgery. She is not taking any current medications. Assessment 1. Tenderness on the Right lower quadrant Plan 1. Quantitative Beta HCG, Ultrasound (Pelvic) 2. CBC, BMP, Urinalysis, Urine Culture 3. No medication prescribed
C/O: Abdominal Pain HPI: Pt is a __ y.o. pregnant female who presents to ED with c/o right lower abdominal pain. Pt is a G2P1. Pt woke up this morning to pain. Pt reports feeling fine yesterday. Pt reports OB visit yesterday for pregnancy and yeast infection. Pt reports pain is a "sharp constant 5" in lower right quadrant. Pt reports nausea and vomiting. Pt denies BM changes, fever, CP, SOB, cough, and bleeding. Pt denies taking Tylenol. Pt took medications from OB yesterday for yeast infection with no relief. Pex normal exam abd - RLQ tenderness, no guarding, no rebound
missed out on pt. wks - check chart review don't forget histories!! - no pmhx, no surgery get the OB visit story accurate - cross check triage, chart review ^ she went to OB for pregnancy and was dx with Yeast Infection
HPI: A thirty-year-old female patient came in with a chief complaint of a sudden right lower quadrant abdominal pain that started this morning when she woke up at seven o’clock. She described the pain as constant and sharp. She rates the pain as five over ten. She reported that she is expecting her second baby, she is in her sixth week of pregnancy and is experiencing yeast infection with discharge. She admits being nauseous and vomited twice earlier today. She denies fever, changes in bowel and any burning symptoms, urinary urgency, or frequency. She denies having headaches, chest pain, shortness of breath, cough, and swelling, or rashes. She denies taking any medications for her symptoms. She denies any history of surgery.
Assessment: A female patient came in with a chief complaint of sudden abdominal pain that started this morning. Physical Exam results are normal except for tenderness in her right lower quadrant.
Plan: 1. The patient undergo physical examination the results were normal except for Right lower quadrant tenderness 2. The doctor ordered for the following tests: Pelvic Ultrasound, Quantitative Beta HCG, CBC, Urinalysis, and Urine Culture. 3. No medications were prescribed.
Pt is a young female who came in with complaints of right lower abdominal pain since 7 am this morning, She got up from bed and suddenly felt a sharp constant pain. She is also experiencing nausea and vomiting, She describes the abdominal pain as a 5/10. Pt is 6 weeks pregnant, G2 P1. She mentioned she went to her OB 6 weeks ago, she was diagnosed with a yeast infection and was given Monistat to treat the infection. She is having some vaginal discharge along with her infection. Denies recent surgeries, fever, chills, SOB, chest pain, dysuria, hematuria, bowel/ Urine incontinence, abnormal gait, vaginal bleeding, and cough.
CC: Abdominal Pain
HPI:
The patient is a __-year-old woman who is 6 weeks pregnant and presenting today with constant abdominal pain. She experienced a sudden onset of sharp and constant pain in the right lower quadrant when she got up this morning at 7 am. She rates the severity of the pain as 5 out of 10. The patient denies taking any medication for the pain.
The patient mentions a recent visit to her obstetrician, who prescribed Monistat for a yeast infection, but the medication did not relieve her abdominal pain. She denies taking any other medications and has no history of medical problems related to her abdomen or any surgeries. This is her second pregnancy, with her first child being 3 years old.
The patient denies having a fever but reports experiencing nausea and has vomited twice. The patient denies changes in her bowels, symptoms of urinary frequency, urgency, or burning. The patient confirms that the pain does not spread to other areas and remains localized in the right lower quadrant. The patient denies taking Tylenol. She denies loc, cp, sob, leg pain/swelling, and rash.
CHIEF COMPLAINT: Abdominal pain
HPI
This six-week pregnant patient came to the clinic with complaints of abdominal pain in the right lower quadrant. The patient claims she woke up at 7 o’clock this morning when she felt a sharp, sudden pain on her side, she describes the pain as consistent and rated it as 5/10 on the pain scale. She visited her OB yesterday due to vaginal discharge and reveals that she is positive for Yeast infection and Monistat was prescribed. She reported that she felt nauseous and vomited (2x). She denies having a fever, headache, presence of some rashes, and changes in bowel movement. She also reports that there are no unusual symptoms such as vaginal bleeding, shortness of breath, and chest pain. She denies any previous surgery. She is not taking any current medications.
Assessment
1. Tenderness on the Right lower quadrant
Plan
1. Quantitative Beta HCG, Ultrasound (Pelvic)
2. CBC, BMP, Urinalysis, Urine Culture
3. No medication prescribed
C/O: Abdominal Pain
HPI:
Pt is a __ y.o. pregnant female who presents to ED with c/o right lower abdominal pain. Pt is a G2P1. Pt woke up this morning to pain. Pt reports feeling fine yesterday. Pt reports OB visit yesterday for pregnancy and yeast infection. Pt reports pain is a "sharp constant 5" in lower right quadrant. Pt reports nausea and vomiting. Pt denies BM changes, fever, CP, SOB, cough, and bleeding. Pt denies taking Tylenol. Pt took medications from OB yesterday for yeast infection with no relief.
Pex
normal exam
abd - RLQ tenderness, no guarding, no rebound
missed out on pt. wks - check chart review
don't forget histories!! - no pmhx, no surgery
get the OB visit story accurate - cross check triage, chart review
^ she went to OB for pregnancy and was dx with Yeast Infection
Stay healthy 👍🏻👍🏻
CC:
Abdominal Pain
HPI:
A thirty-year-old female patient came in with a chief complaint of a sudden right lower quadrant abdominal pain that started this morning when she woke up at seven o’clock. She described the pain as constant and sharp. She rates the pain as five over ten. She reported that she is expecting her second baby, she is in her sixth week of pregnancy and is experiencing yeast infection with discharge. She admits being nauseous and vomited twice earlier today. She denies fever, changes in bowel and any burning symptoms, urinary urgency, or frequency. She denies having headaches, chest pain, shortness of breath, cough, and swelling, or rashes. She denies taking any medications for her symptoms. She denies any history of surgery.
Assessment:
A female patient came in with a chief complaint of sudden abdominal pain that started this morning. Physical Exam results are normal except for tenderness in her right lower quadrant.
Plan:
1. The patient undergo physical examination the results were normal except for Right lower quadrant tenderness
2. The doctor ordered for the following tests: Pelvic Ultrasound, Quantitative Beta HCG, CBC, Urinalysis, and Urine Culture.
3. No medications were prescribed.
Appendicitis