Pelvic Discomfort ER Sample Report
DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Pelvic discomfort.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with pelvic pain of approximately one month’s duration. She was evaluated in the emergency room for these symptoms, diagnosed with ovarian cyst pain as a likely etiology for her abdominal discomfort. Because the patient is without insurance at this time, her mother presents her to the ER.
Symptom onset is constant and has been present the past month, perhaps the pain is little worse over baseline. Pain is rated at mild to moderate. The patient cannot identify any aggravating or relieving factors at this time. She states she has a vaginal discharge that is clear. No urinary frequency with or without dysuria, no back pain, denies nausea, vomiting. No fever or chills. Last menstrual period, the first week of March.
PAST MEDICAL HISTORY: Unremarkable.
PAST SURGICAL HISTORY: None.
SOCIAL HISTORY: Single. Denies tobacco, alcohol or street drug use. The patient is a (XX)th grade student who attends school.
FAMILY HISTORY: Diabetes mellitus and asthma.
PERSONAL PHYSICIAN: Primary care provider: None at this time. Previously, primary care provider was Dr. John Doe.
REVIEW OF SYSTEMS: The 13-system review was significant for items identified in the HPI and past medical history.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is a well-nourished, well-developed (XX)-year-old female, nontoxic appearance.
VITAL SIGNS: Blood pressure 124/72, pulse 94, respirations 18, temperature 97.2, pulse oximetry on room air 97%, and weight 80 kilos.
HEENT: Head is normocephalic and atraumatic.
NECK: Supple without nodes or masses.
CHEST: Clear without rales, rhonchi or wheezes.
HEART: S1 and S2. Regular rate and rhythm without murmur or gallop.
ABDOMEN: Soft and nontender. Bowel tones present. No rebound tenderness or guarding. Murphy sign is negative. McBurney point is negative. No costovertebral tenderness. No abdominal masses.
PELVIC: External genitalia: Normal in appearance. Cervix: Upper lip is red and swollen. STD cultures obtained. Bimanual: Without pain or mass. Uterus is nontender. Chandelier is negative.
EXTREMITIES: No peripheral clubbing, cyanosis or edema. Peripheral pulses are +2. Capillary refill less than 1 second.
DIAGNOSTIC DATA: Pelvic ultrasound reveals a normal size uterus with a thick endometrium, 1.3 cm, probable bicornuate uterine anomaly. A 2.5 cm left ovarian cyst. No adnexal mass or free pelvic fluid.
LABORATORY DATA: Urinalysis is negative. Bedside pregnancy test is negative. GYN cultures are pending.
EMERGENCY DEPARTMENT COURSE: Rocephin 125 mg IM, Zithromax 1 gram p.o., Zofran 4 mg ODT for nausea control with good results, Toradol 60 mg IM for pelvic discomfort with good results.
IMPRESSION:
1. Left ovarian cyst.
2. Cervicitis.
PLAN:
1. Discharge instructions provided to the patient and her mother for review.
2. Doxycycline 100 mg p.o. b.i.d. x10 days.
3. Ibuprofen 600 mg t.i.d. with food for at least one month in an attempt to inhibit prostaglandin activity.
4. Tylenol No. 3 one tab p.o. q. 4-6 hours p.r.n. pain, #20, no refills.
5. Return to the ER tomorrow for culture results.
The patient and mother were in agreement with this plan.
DISPOSITION/CONDITION: Discharged in stable and improved condition.
