AOP FNP 2 & 3 H&P/ Initial Consultation template

Patient: 22 year old female

DOB: 7/5/2000

Visit Date: 4/4/2023

CC: Abdominal pain

HPI: Patient is a 22-year-old female presenting to the ED for abdominal pain after having sexual
intercourse. Patient presents to emergency department with male friend and the report they had sexual
intercourse over the past two days and states that she has had extreme abdominal pain to her the lower
mid abdominal region. Pt endorses sexual intercourse increases pain and has no alleviating factors. Pt
describes pain as sharp and stabbing. Pt denies any radiation of pain and rates it 10/10 currently. Patient
reports that the pain was so bad that she “passed out” but stayed she never fell and just laid in bed.
When asked further patient and friend state it was for approximately an hour. Patient denies any chest
pain, shortness of breath, recent long travel, headache, or visual disturbance. She does report feeling
nauseous but no vomiting, diarrhea, fevers, or illness. She denies hematuria, dysuria, urinary frequency,
unusual lesions, sores, or vesicle formation. Pt denies any concern for STDs or pregnancy.

Past Medical History:

Congenital Deafness

Family History:

Pt states endorses she was adopted and does not know biological family or familial past medical history.

Social History:

Patient reports that she does not currently or has ever used alcohol. Patient denies present and past
drug use. Pt has never used any tobacco products.

Review of Last Lab results:

This is the first-time patient has been seen in this emergency department.

Allergies:

No known drug allergies

Current Medications:

Patient is not currently on any medications.

Review of Systems (ROS):

 Constitutional: Denies appetite change, fevers, injuries

HEENT: Denies any frequent or severe headache; no history of head trauma, dizziness. No eye
infections, change in vision, ear infections, neck pain, limitation in motion or throat infections. Pt states
she has a loss of consciousness for approx. 1 hour while laying down in bed.

Respiratory: Denies cough, shortness of breath and chest tightness. No history of respiratory disease
or sick contacts. Pt denies smoking cigarettes or use of vaping products.

Cardiovascular: Denies chest pain, palpitations, fatigue, and edema.

Gastrointestinal: Pt denies abdominal distention, constipation, and diarrhea. Pt complaining of lower

mid abdominal pain x2 days, increasing with sexual intercourse rated 10/10 at this time. Pain is
described as sharp and stabbing and is constant in nature. Complaining of nausea, denies vomiting.

Genitourinary: Denies dysuria, hematuria, urinary frequency, and urinary retention. Pt denies any
concern for pregnancy or STDs. Pt denies unusual lesions, sores, or vesicle formation

Musculoskeletal: Denies joint pain, stiffness, swelling or limitation. No muscle pain or weakness. No
history of any obvious injury.

Neurological: No head injury, dizziness, weakness, seizures, vertigo, or tremors. Denies numbness and
tingling. No history of stroke. Pt states she had a loss of consciousness for approximately 1 hour while
laying down in bed.

Hematological: Denies any bruising, bleeding, and epistaxis

Psychiatric/ Behavioral: Denies anxiety, depression, aggressive behaviors, SI and HI.

Physical Exam:

Vital signs: HR 91, RR 16, BP 127/64, 98% RA, Temp 98.4 F

Height 5f 7in, weight 173lb BMI 27.1 (overweight)

Constitutional: Young adult in no acute distress. Afebrile.

Appearance: She is well developed, overweight with a BMI of 27.1

HEENT:

Head: Normocephalic, atraumatic, and symmetric

Eyes: PEERLA, pupils 3mm bilaterally, healthy vision function, healthy eye structures

Ears: External skin intact with no masses, lesions, tenderness, or discharge. Congenital
deafness

Neck: Full ROM, no pain. Trachea midline.

Throat/Mouth: Symmetric, no skin lesions. Thyroid not enlarged, mucous membranes are
moist and pink

Cardiovascular:
 Rate and rhythm: Rate 91, rhythm regular. No murmurs, gallops, pause or skips.

Pulses: Normal pulses 2+

Pulmonary:

Effort: Respirations 16/min, are easy and unlabored. No accessory muscles used. Chest
expansion symmetric. Breath sounds: Bilateral breath sounds clear throughout anterior and
posterior lobes.

Abdominal:

General: Normoactive bowel sounds present in all 4 quadrants.

Abdomen: Abdomen is soft, flat, symmetric with no apparent masses. No distention.

Abdominal tenderness noted to lower mid region with no rebound tenderness. Pelvic exam
performed with no complication. No discharge, blood, clots are seen within the vaginal vault.
Cervix appears to be closed. No pain during by manual examination while palpating abdomen.

Lymphadenopathy:

No lymphadenopathy

Musculoskeletal:

Normal ROM upper and lower extremities. No edema of upper or lower extremities

Skin:

Warm to touch, dry smooth and even. No lesions, bruises, or lacerations.

Neurological:

Mental Status: Alert and oriented x4. Cranial II through XII grossly intact. No neurological
deficit.

Motor: No tremor or abnormal muscle tone

Deep Tendon Reflexes: 2+ deep tendon reflexes.

Psychiatric/ Behavioral:

Attention, mood, and affect normal. Good eye contact. Behavior and cognition are normal. No
memory impairment.

Lab Tests Orders: (include ICD-10 codes)

Wet Prep, Genital R87.5

C. Trachomatis N. Gonorrhoeae A74.9

CBC W/ Auto Diff R68.89

CMP Z13.228
 Lactic Acid R74.0

Urinalysis 810003

POC Pregnancy Urine O23.40

Diagnostic Tests Orders: (include IDC-codes)

CT Head WO Contrast R93.0

US Non OB Transvaginal 76830

EKG R94.31

Results:

Patient received a pelvic exam. Pelvic exam tolerated well with no complications. Cervix appears closed.
No clots, blood, discharge was seen within the vaginal vault. On bi-manual examination patient did not
have any tenderness while palpating the abdomen. CMP showed potassium of 5.9 and was moderately
hemolyzed, CMP was redrawn and was completely unremarkable with potassium of 3.9 and no
hemolysis. CBC has no abnormal findings. Hemoglobin 12.4 hematocrit 37.6. Urinalysis shows no
leukocyte esterase, ketones, or white blood cells. Patient negative for urinary tract infection. Lactic acid
with a normal limit at 0.9. Point of care pregnancy test negative. Per the wet prep there are no
abnormal findings. Patient received Toradol 30 mg IV once and Zofran 4 mg IV once in emergency
department for symptom relief regarding abdominal pain and nausea. CT of the head was unremarkable
with no mass or hemorrhage. Ultrasound reading demonstrates normal myometrial echotexture.
Endometrium is thickened and mildly heterogeneous. Right ovary: complicated cystic structure within
the right ovary measures 29 mm. Appears to contain some internal septations and what appears to be a
retracting clot. Probable hemorrhagic cyst. There is normal arterial and Venus Doppler flow. No right
adnexal mass. Left ovary shows cystic structure within the left ovary which also contain some internal
septations and what appears to be a retracting clot. Probable hemorrhagic cyst. This measures 26 mm in
largest dimension. There is normal arterial Venus Doppler flow. No left adnexal mass. There is a small
amount of simple appearing fluid identified in the right hemipelvis and cul-de-sac.

12 lead EKG as interpreted by the emergency room attending and myself. Heart rate of 91. Normal sinus
rhythm. No ST elevation or depression noted. Normal axis deviation. No previous EKGs for comparison.

Assessment & Plan: (Include Primary Diagnosis* and Pertinent Diagnosis with ICD-10 codes related to
overall plan of care)

Hemorrhagic cyst of ovary* N83.291

 Follow up with OB/GYN in 1-2 days. In many cases hemorrhagic cysts go away on their own
however if the cyst is > 10 cm surgery may be considered. Patients’ bilateral cysts are 19mm on
the right and 26mm on the left.
 Recommended follow up pelvic ultrasound in 10-12 weeks to reassess the bilateral ovaries and
endometrium. Specifically, it is important to obtain this ultrasound within the first 10 days of
menstrual cycle.
 Repeat labs per OB/GYN for monitoring of hemoglobin and hematocrit.
  Patient received Toradol 30 mg iv once and Zofran 4mg iv once in emergency department for
symptom relief.

Abdominal pain R10.9

 Patient received Toradol 30 mg iv once and Zofran 4mg iv once in emergency department for
symptom relief.
 Patient instructed to abstain from sexual intercourse.
 Patient given prescription for naproxen 500 mg bid x7 days for symptom relief until seen by
OB/GYN. Non-steroidal anti-inflammatories reduce prostaglandin levels which are elevated in
women with excessive bleeding. With pt having hemorrhagic cysts and upcoming menstrual
cycle this is the best option to prevent further blood loss or complications.
 Follow up with OB/GYN in 1-2 days

Vasovagal syncope R55

 Manage pain with Naproxen prescription alternating with Tylenol.

 Drink plenty of fluids including water, Gatorade and Pedialyte.
 Abstain from sexual intercourse due to circumstances surrounding the loss of consciousness
may be related to pain.

Dyspareunia N94.1

 Pt instructed to abstain from sexual intercourse until follow up with OB/GYN in 1-2 days
 Pt instructed to avoid any type of penetration to vagina until pain is controlled and OB/GYN
states it is okay.
 Pt is instructed to monitor periods or vaginal bleeding in a journal
 Follow up with OB/GYN in 1-2 days

Follow up :

Patient is deaf and uses American Sign Language, interpreter brought up again to explain discharge
instructions to patient. Patient is diagnosed with two hemorrhagic ovarian cysts. Patient instructed to
follow up with OB/GYN in 1-2 days. Patient given a prescription for a naproxen for symptom relief.
Patient instructed to abstain from sexual intercourse, and until follow up with OB/GYN takes place and
pain subsides. Pt instructed to keep notes or journal of vaginal bleeding and length of periods. Patient
signs that she understands discharge instructions with OB/GYN and strict return precautions. Patient is
stable for discharge.

CPT / E&M Charges: 99281

Student Signature Tori McCormick Date 04/4/23