Pamela SOAP.docx - Pamela 24 y\/o F G0P0 PMH of chlamydia c\/o pelvic pain and vaginal bleeding for 24 hours The pelvic pain is deep changed from

Pamela SOAP.docx - Pamela 24 y/o F G0P0 PMH of chlamydia...

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Pamela 24 y/o F G0P0 PMH of chlamydia c/o pelvic pain and vaginal bleeding for 24 hours. The pelvic pain is deep, changed from intermittent crampy to constant intense sharp pain in LLQ, 8, w/o radiation, IBU gave initial relief but no longer controls pain, lying still alleviates and movement (bending) worsens. Bleeding has been constant and amount is similar to a heavy period, denies menstrual sx. Pt reports irregular menstrual hx, usual normal flow, w/ menstrual sx. LMP is unknown. The pt has PMH of appendectomy, exercise asthma, and treated chlamydia. Pt reports inconsistent use of condoms and does not take OCP, sexually active w/ boyfriend. T 98.8 F, HR 104, R 14, BP 108/60 mmHg, AOx4 (+) findings: LLQ tenderness to palpation, guarding in LLQ and RLQ, severe pain w/ bimanual exam, left adnexal fullness, blood noted in vagina and cervical os. (-) findings: -orthostasis, -pallor, capillary refill <2s, heart RRR, lungs CTA, normoactive bowel sounds
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  • Fall '20
  • Ectopic pregnancy, Pelvic pain

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