Joanna Morino

CC- Abdominal pain

DOB: 12/09/1992
NKDA

S- 22 year old Caucasian Female presents to the clinic complaining about an abdominal
pain since last 2 days. Patient describes the pain to be constant, sharp/ throbbing. The
pain is located in RLQ. Pain is gradual in onset and worsening since today morning and
there are no alleviating factors. Pain is aggravated with movement. Patient denies
vomiting, diarrhea, lower back pain and hematuria but does admit that she has dysuria,
urinary urgency and increased frequency and yellowish vaginal discharge. Patient is
sexually active in monogamous relationship since last 3 months. Inconsistently uses
condom. Last menstrual period was 5 weeks ago. She has a regular 26 day cycle. Patient
denies having gonorrhea or Chlamydia. Last PAP was 2 years ago which was normal.
PMH:
Overall unremarkable. Occasional cold/ flu. Denies hx of diabetes, HTN, cancer, asthma.
Surgical HX: Tooth extraction at age 9
Psychiatric Hx: None
Social: Senior in college. She appears to be in pain and discomfort. EtOH on weekends
around 6-7 beers and some vodka shots with friends. Denies smoking and use of illicit
drugs.
FMH :
Both father and mother have diabetes. Mother also has HTN. No family history of IBS,
obesity, stroke, kidney disease, lung disease, vascular disease, liver disease, seizure
disorder, or mental illness.
Medication: Advil Prn.
Allergies: penicillin (hives).
ROS (Review of Systems):
Eyes: Denies headache, visual changes, double vision, and eye pain, floaters or blind
spots (scotomas).
Neuro: WNL.
Ears, nose, mouth and throat (ENT): Denies sinus pain, pain with swallowing, sore
throat. Pt. denies stuffy or painful ears, toothache.
Cardiovascular: Pt. denies shortness of breath, loss of consciousness, edema, chest pain
or palpitations.
Respiratory: Denies cough, haemoptysis, exercise intolerance, wheezing, and sputum.
Lungs are clear to auscultation.
Abdomen: abdominal pain, denies constipation or diarrhea, N/V, or changes in stool
pattern.
(O) OBJECTIVE
PE (Physical examination)
VS: P 90, B/P 135/82, Temp 39.7 height 55, Weight 122 lb
General: Alert & oriented x3, well nourished, well groomed, appropriate affect, in

discomfort. Responds appropriately to interview and questions.

HEENT (head, eyes, ears, neck and throat): Normal
Neck: Supple, no lymphadenopathy, no bruits
Skin: WNL
Cardiovascular: Femoral pulses 2+, RRR having S1, S2, no murmurs, gallops or rubs.
Respiratory: Bilateral breath sounds (BBS) clear to auscultation
Abdomen: BS present x 4 quads, normoactive, soft, non-distended, lower abdominal
pain and tenderness.
Neuro: Cranial Nerves Intact and functioning well.
Pelvic examination: negative for lymphadenopathy, skin lesions and rashes.
Assessment
Urine test for UTI and pregnancy.
PID possible for gonorrhea or chlamydia.
Bacterial vaginitis
Trichimonas
Ectopic pregnancy
Cervicitis
Perform the speculum and bimanual exam. Observed cervical motion and tenderness.
Plan:
Diagnosis confirmed PID. Treatment for Gonorrhea is ceftriaxone and
Chlamydia is azithromycin. Call the partner for treatment counseling
on this chart advised pt. to have safe sex with use of protection. Ask
them to have done pelvic examination every year.