Patient Information
Nancy Penn is a 22 year old female.
History is provided by the patient, who is a reliable source.
Chief Complaint
“I’m having
... [Show More] some bad pelvic pain. It just started suddenly about an hour ago.”
Present Illness
Nancy Penn is a 22 year old female with a history of PID, who presents to the ED with severe
sharp 9/10 lower pelvic pain that started one hour ago with nausea and lightheadedness. She
states her last period was two months ago and is currently one month late. She denies current
abnormal vaginal bleeding but did have a scant bit of spotting two days ago. She is sexually
active with her boyfriend and uses condom inconsistently. She denies trauma to her pelvis.
Past Medical History
Pelvic Inflammatory Disease – One year ago and was treated with antibiotics.
Surgical History
None
Hospitalization
None
Allergies
None
Health Maintenance
Immunization: Up To Date
Pap Smear 4 months ago was normal.
Family History
Father is 51 years old and is healthy.
Mother is 50 years old and is healthy.
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Personal and Social History
Patient is a student.
Patient has a boyfriend.
Lives with roommate in an apartment complex.
Alcohol: Drinks occasionally on weekends, holidays, and when hanging out with friends.
Tobacco: Only once in a while when drinking.
Illicit-Drug Use: None
Sexual History
Patient is heterosexual.
Uses condom inconsistently. Only having sexual intercourse with boyfriend.
Medications
None
Review of Systems
General: Refer to HPI.
HEENT: Denies headache, head trauma, loss of vision, blurred vision, double vision, ear pain,
ringing in ears, neck pain, sinus pain, sore throat, and difficulty swallowing.
Cardiovascular: Denies chest pain, heart palpitations and peripheral edema.
Respiratory: Denies cough, shortness of breath, and wheezing.
Gastrointestinal: Reports lower pelvic pain and nausea. Denies vomiting, diarrhea, hiccups,
heartburn, bloating, abdominal pain, and changes in bowel habits.
Genitourinary: Reports scant bit of spotting two days ago and late period. Denies dysuria,
hematuria, pain with intercourse, and changes in bladder habits.
Musculoskeletal: Denies fatigue, muscle or joint pain, muscle cramps, and joint stiffness.
Neurological: Reports lightheadedness when getting up, feeling exhausted, and weak all over.
Denies headache, trouble with speech, memory loss or problems, lack of coordination, tremors,
numbness, and tingling.
Integumentary: Denies skin problems, changes in skin, rashes, and lesions.
Lymphatic/Endocrine: Denies swollen glands, and problems with heat or cold intolerance.
Hematologic: Denies bruising, bleeding gums, nose bleeds, or other sites of bleeding.
Psychological: Denies feeling anxious, sad, depressed, and hopeless.
Physical Exam
General Survey: Patient is alert, moderate distress secondary to pain, and is ill-appearing.
Height, Weight, and Vital Signs: Height: 5’7” Weight: 128 lbs BMI: 20.1
Vitals: Temp: 99.0 F, HR: 120, BP: 89/50, RR: 20, O2: 97% Room Air [Show Less]