Unspecified complication of pregnancy antepartum condition or complication Abdominal pain left lower quadrant
 
Name:  ___         Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: OBSTETRICS/GYNECOLOGY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
abdominal pain
 
Major Surgical or Invasive Procedure:
none
 
History of Present Illness:
___ year-old Gravida 2 Para 1 at 28 weeks 6 days gestational age 
who presented with acute onset left lower quadrant pain while 
laying still in bed. She got up and urinated and it gradually 
worsened to ___. She had never experienced this kind of pain 
before. It was twisting and very sharp in nature and constant. 
Worse with legs extended vs flexed. A couple of hours after the 
pain started, she started to feel uterine tightening. Denied 
fever, chills, nausea, vomiting, diarrhea, dysuria, vaginal 
bleeding, leaking of fluid, hematuria, abnormal vaginal 
discharge. + Fetal movement. Last intercourse the morning prior.
 
Past Medical History:
PRENATAL COURSE
- Estimated Due Date: ___
- labs: A+/Ab-
- screening: GLT wnl, FFS wnl
.
OBSTETRIC HISTORY
Gravida 2 Para 1
(___) @ ___: Vacuum-assisted vaginal delivery @ 34 ___ wks, 
spontaneous preterm labor, had been hospitalized during 
pregnancy @ 30 weeks with vaginal bleeding and received 
betamethasone. 5#4, male

GYNECOLOGIC HISTORY: remote history of chlamydia
.
PAST MED/SURG HISTORY: benign
 
Social History:
___
Family History:
non-contributory
 
Physical Exam:
(on admission)
VS: T 98.3, RR 18, BP 97/66, HR 130->115
GENERAL: crying, lying on her side in fetal position, very 
uncomfortable, able to speak in full sentences
CARDIO: reg rhythm, tachy
PULM: CTAB
BACK: no CVA tenderness
ABDOMEN: soft, gravid, most TTP LLQ just superior to inguinal 
area (no palpable underlying masses) though tender more 
superiorly as well, no R/G, no uterine TTP
EXTREMITIES: NT b/l
SSE: def
SVE/BME: L/C/P

TOCO: no clear ctx

FHT: 150, mod var, AGA, no decels
BPP: ___, cephalic, DVP 5.3, EFW 1328g 2#15oz
 
Pertinent Results:
___ WBC-9.0 RBC-3.95 Hgb-12.8 Hct-36.4 MCV-92 Plt-404
___ Neuts-72.8 ___ Monos-6.3 Eos-1.4 Baso-0.4
___ WBC-9.5 RBC-4.04 Hgb-12.3 Hct-36.4 MCV-90 Plt-417
___ Neuts-70.0 ___ Monos-5.6 Eos-1.1 Baso-0.4
.
___ ___ PTT-31.1 ___ ___
.
___ Glucose-73 BUN-4 Creat-0.5 Na-134 K-4.2 Cl-102 HCO3-22
___ Calcium-8.7 Phos-3.7 Mg-2.0
.
___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG 
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM 
.
Pelvic Ultrasound:
Limited views demonstrate a live single intrauterine gestation 
with
normal cardiac activity. The cervix remains long and closed. 
Please note
that this limited exam does not substitute a full fetal survey.
.
Attention was then directed to bilateral superiorly displaced 
ovaries,
necessitating use of linear probe. The left ovary measures 2.7 x 
2 x 1.5 cm, with normal arterial and venous flow. The right 
ovary measures 2.2 x 1.4 x 1 cm, with normal venous flow. 
Arterial flow on the right is not demonstrated. The ovaries 
appear normal in size and morphology. There is no focal 
tenderness over the superiorly displaced ovaries.
. 
Targeted ultrasound was performed to the site of symptomology in 
the lower
abdomen, away from the ovaries, demonstrating no focal 
pathology.
. 
IMPRESSION:
1. Normal size and morphology of bilateral ovaries. Normal 
vascularity of
the left ovary. Limited arterial assessment of the right ovary.
2. Limited exam of single intrauterine gestation with normal 
cardiac activity and closed cervix. For full assessment of the 
fetus, continued routine fetal followup is recommended.
3. Tenderness in the lower abdomen is away from superiorly 
displaced ovaries. No discrete pathology is demonstrated at the 
site of symptom.
 
Brief Hospital Course:
Ms. ___ received 0.5mg of IV Dilaudid in triage and her pain 
greatly improved.  As above, her pelvic ultrasound was negative 
for any pathology and her laboratory studies were unrevealing.  
She did not require any additional analgesics and was admitted 
to the antepartum floor for close observation and abdominal 
exams.  While there, she had an episode of emesis after eating 
and began having chills and feeling generally unwell with no 
abdominal pain, but abdominal discomfort.  She remained afebrile 
with no elevation of white count and had no other focal signs or 
symptoms.  It was thought that she had a mild viral gastritis.  
Her left lower quadrant pain never returned.  She was given 
zantac, oral zofran and IV hydration and by the afternoon on 
hospital day #2 was feeling better.
.
Fetal testing was reassuring by ultrasound and non-stress 
testing.  She had no signs of labor and her cervix remained 
closed.
.
She was discharged home on hospital day #2 symptomatically 
improved.
 
Medications on Admission:
prenatal vitamin
folic acid
 
Discharge Medications:
prenatal vitamin
folic acid
 
Discharge Disposition:
Home
 
Discharge Diagnosis:
pregnancy at 29+0 weeks gestation
suspected viral gastroenteritis
 
Discharge Condition:
stable
 
Discharge Instructions:
stay well hydrated
 
Followup Instructions:
___

{'abdominal pain': ['Abdominal pain', 'left lower quadrant'], 'twisting and very sharp in nature and constant': ['Abdominal pain', 'left lower quadrant'], 'worsen with legs extended vs flexed': ['Abdominal pain', 'left lower quadrant'], 'uterine tightening': ['Abdominal pain', 'left lower quadrant'], 'fever, chills, nausea, vomiting, diarrhea, dysuria, vaginal bleeding, leaking of fluid, hematuria, abnormal vaginal discharge': []}