History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Essential Differential Diagnosis
Relevant Testing
Test Results
Diagnosis
Treatment Orders
Question 1
Question 2
Question 3
About the Case
Abdominal Pain in a 26-Yr-Old Pregnant Woman
Physical Examination
General appearance
: Well-developed female, appears tired and ill but in no apparent distress.
Vital signs
:
Temperature: 38.8° C
Pulse: 120 beats/minute
BP: 110/76 mm Hg
Respirations: 20/minute
Skin
: Hot, diaphoretic. No rash or cyanosis.
HEENT
: Dry mucous membranes, no scleral icterus or conjunctival injection, neck is supple, no adenopathy.
Pulmonary
: Breath sounds are equal bilaterally with good air movement in all fields. There are faint inspiratory crackles present on the left side heard more at the base. No wheezing.
Cardiovascular
: Mild tachycardia with regular rhythm; no murmurs, rubs, or gallop. No peripheral edema.
Gastrointestinal
: Bowel sounds normal. Abdomen soft, diffusely tender across the lower abdomen bilaterally with no guarding, rigidity, or rebound. No tenderness in the upper quadrants, gravid, non-tender uterus 2 cm below the level of the umbilicus. No inguinal or femoral hernias. Rectal examination non-tender, stool brown, heme negative.
Genitourinary
: Normal external genitalia, no cervical motion tenderness, scant thin white discharge from the cervical os, which appears closed. Fetal heartbeat regular at 150 beats/minute.
Musculoskeletal
: No swelling, tenderness or deformity of joints or extremities. Positive costovertebral angle tenderness bilaterally.
Neurologic
: Unremarkable
Mental status
: Alert and oriented, with fluent and coherent speech.
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