Patient Information: J.M., 47y/o, Hispanic, Female S. CC (chief compla

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Patient Information:
J.M., 47y/o, Hispanic, Female

S.

CC (chief compla

Patient Information:
J.M., 47y/o, Hispanic, Female

S.

CC (chief complaint): lower abdominal cramping, and urinary leakage

HPI:
47y/o Hispanic female presents to the office for complaint of lower abdominal
cramping and urinary leakage that began several hours ago. The abdominal pain is located in the suprapubic region. She describes the pain as sharp, intermittent, and becoming more frequent and increasingly painful, with some associated Incontinence. She reports that she has taken Motrin, but states it does not help. She reports having similar pain years ago with a UTI. Pain severity was not rated on 0-10 scale (would ask). She does not report any other aggravating or relieving factors (would ask). She also reports some fatigue over the last few months, states that her LMP was 8-12 months ago, and believes she endured an easy menopause.

Allergies: No drug allergies or supplement allergies, no environmental allergies, no food allergies.

Medications: No daily medications; Motrin for pain (dose unknown)

PMHx: immunization status unknown; Hx UTI, possible menopause; denies having any prior surgeries or severe illnesses.

Social / Substance Hx: denies any use of alcohol, tobacco, recreational drugs or other substances; no health promotion info provided (would ask)

Family Hx: None provided (would ask)

Surgical Hx: Denies previous surgical procedures.

Mental Hx: None provided (would ask)

Violence Hx: Safety and partner safety / information was not provided (would ask)

Reproductive Hx: LMP: 8-12 months ago; G5 P5 LC 6; contraceptive use – previously utilized NFP prior to cessation of menstrual cycle;
Sexual preference and practices information not provided (would ask)
gender and sexual preference not reported (would ask)

ROS:
GENERAL: No weight loss, fever, chills, weakness; +fatigue for past several months.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears,
Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rashes, lesions, bruises, or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No
palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: +Reports suprapubic abdominal pain; +reports constipation and increased gas for the last several months.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or
tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia or bruising or swollen lymph nodes.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or
polydipsia. +Fatigue.
GENITOURINARY/REPRODUCTIVE: +urinary incontinence. denies burning on
urination. Would ask more about frequency and amount of urine with each void. LMP: 8-12 months ago – exact date unknown. +Nipple discharge yellow/white in color. Denies prior history of breast lumps or pain. Reports some vaginal spotting several days ago (would ask for more details, such as color, odor, burning sensation, amount, frequency, and any other associated symptoms such as pain with intercourse, etc).
Unknown if patient is sexually active (again, would ask about preferences and practices).

ALLERGIES: Denies any allergies to medications, supplements, food or environmental allergies.

O.

Vital signs: temperature 99.1, BP 140/ 82, pulse 88, respirations 12. Height is 5′ and
weight 235 lbs. (BMI 45.89).
General: Limited physical exam shows well developed, obese Hispanic female, in
no apparent distress. A&Ox4, pleasant and cooperative.
Heart: regular rate and rhythm, no murmurs. Currently with hypertension.
Lungs: Clear to auscultation. No adventitious sounds or labored breathing.
Breasts: pendulous, bilateral white/yellow nipple discharge noted. No masses, lumps, or densities.
Abdomen: obese, ? mass in Abd but difficult to assess due to body habitus, otherwise soft
and non-tender. Fungal dermatitis under pannus.
CVA: No cva tenderness.
VVBSU: WNL, some watery d/c noted, nitrazine positive. Vagina with pink with
rugae present. Good pelvic support, no cystocele or rectocele noted.
Cervix: soft, smooth without CMT, os parous, slightly open (would measure)
Uterus: difficult to assess due to body habitus however feels enlarged by bi manual
exam. (would consider fundus measurement if able due to consideration of possible pregnancy)
Adnexa: not palpated

Diagnostic results: A clean catch urine was obtained for urinalysis, results of urine dipstick
showed SG 1.010, trace blood, neg nitrates, neg leukocytes, negative glucose, 3+ protein.

A.

Z32.00: Encounter for pregnancy test, result unknown – As evidenced by the signs of possible pregnancy including lack of a more reliable birth control method, lack of period for 8-12 months, presence of uterine enlargement on bimanual exam, fatigue, and light yellow nipple discharge. Would check for placenta previa if she is pregnant due to bleeding. Would also consider the possibility of a miscarriage and chances/risks of an older age in pregnancy. Would also consider gestational hypertension if greater than 20 weeks pregnant due to evidence of proteinuria and elevated blood pressure, and risk factor of elevated BMI, which would also lead me to test for diabetes and gestational diabetes (Catalano & Shankar, 2017).
N39.0: Urinary tract infection, site not specified – As evidenced by signs of a UTI including new onset of urinary incontinence, proteinuria, low grade fever, and possibility of blood being from the urinary tract rather than the vagina. Cystitis is another possible relative ddx next to this.
N20.9: Urinary calculus, unspecified- As possibly evidenced by proteinuria, incontinence, and suprapubic pain. Some kidney stones are asymptomatic at first and proteinuria is sometimes one of the first indicators of an underlying stone (Haider & Aslam, 2023).
N80: Endometriosis- As possibly evidenced by suprapubic pain, enlarged uterus on palpation during bimanual exam, spotting, fatigue, constipation / bowel issues, increased urinary frequency (Edi & Cheng, 2022).

P.

Orders: urine HCG, abdominal/pelvic ultrasound, CBC, CMP, TSH, prolactin,
FSH & LH, urine culture.

[Patient education, treatment and follow-up will vary greatly depending on the outcome of the pregnancy test and other ordered tests.]

References:

Catalano, P. M., & Shankar, K. (2017). Obesity and pregnancy: mechanisms of short term and long term adverse consequences for mother and child. BMJ (Clinical research ed.), 356, j1. https://doi.org/10.1136/bmj.j1

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