Nancy Penn – OBGYN Case Study LATEST Update 2020 2021 - Is it possible you’re pregnant/ breast tender/ bleeding between cycles Pretest- actions for
... [Show More] acute abdominal pain
• Asses for signs of shock / hemodynamic instability
• Pregnancy test (for all women of childbearing age)
• Order blood products immediately in unstable patients with suspected active hemorrhage
• Obtain/Preform bedside imaging in unstable patients with suspected pneumoperitoneum or hemoperitoneum.
• Administer Antibiotics early in the setting of sepsis, peritonitis, or perforated viscous
• Provide adequate analgesia
• Obtain immediate surgical consultation in the setting of an acute abdomen with hemodynamic instability.
Diagnosis – Ectopic pregnancy
Tests- hcg urine, ua, pelvic ultrasound, cbc
Problem Statement:
( Demographic description – chief complaint – Hx and PE key findings – risk factors )
Nancy Penn is a 22 year old female G0P0 presenting with severe stabbing 9/10 diffuse pelvic pain that started 1 hour ago. She is tachycardic (R=120) and hypotensive (89/50 mmHg) and nauseated.
Genitourinary exam shows cervical motion tenderness and tenderness to uterine palpation without masses. She is sexually active with her boyfriend and uses condoms inconsistently. She has a history of PID 1 year ago treated successfully and reports her period was 2 months ago and is 1 month late.
CC: Nancy Penn is a 22 year old female G0P0 presenting with severe stabbing 9/10 diffuse pelvic pain that started 1 hour ago.
HPI: She reported the pain came on suddenly and sharply. She also reports with the pain – nausea and lightheadedness upon standing. Patient reports her last period was 2 months ago.
Meds: none.
PMH: Patient occasionally smokes, and has a history for pelvic inflammatory disease 1 year ago.
SH: Patient is sexually active with her boyfriend and inconsistenly use condoms
ROS: Only positive findings are seen in HPI
Physical Exam:
VS: Pulse – 120 tachycardic; BP – 89/50 hypotensive RR – 20; T – 99F (37 C); SpO2 – 97% [Show Less]