Identifying Data: 

Full Name: XX

Address: XX

Date of Birth: XX

Date & Time: 03/17/24 1AM

Location: New York Presbyterian Hospital, Queens

Religion: Christian 

Source of Information: Self and Father

Reliability: Reliable 

Source of Referral: Self 

Mode of Transportation: Self 

 

Chief Complaint: “belly ache” x 2 days 

History of Present Illness: 

A 21 year old female with no PMHx presents to the ER with her father, complaining of left lower quadrant abdominal pain that started 2 days ago. Patient states the pain is a sharp, 10/10 pain that comes and goes but stays constant for long periods of time. The pain does not radiate to the groin or the back, it stays localized to the left lower quadrant. She has had two episodes of nonbloody, nonbilious vomiting and two episodes of nonbloody and non mucousy diarrhea in the last two days. She reports that nothing makes it better or worse, and has not taken any medications to alleviate her symptoms. She reports that her LMP was 2 weeks ago and endorses regular monthly menstruation. She denies being currently sexually active or ever in the past. Denies fever, chills, dysuria, hematuria, abnormal vaginal bleeding. Denies history of kidney stones. Denies any prior abdominal surgeries. Denies any sick contacts or recent travel. 

Past Medical History: 

Present Illnesses – None

Immunizations: Fully up to date

Childhood illnesses: None 

 

Past Hospitalizations: 

None

 

Past Surgical History:  

None

 

Medications: 

Vitamin D daily 

 

Allergies: 

No known food allergies

No known drug allergies

 

Family History: 

Mother – alive and well

Father – alive and well

No siblings.

Maternal Grandmother – deceased

Maternal Grandfather – deceased

Paternal Grandmother –  deceased 

Paternal Grandfather –  deceased

 

Social History: 

Ms. JC is a female living in her house with her mother and father. She is currently a college student.

Habits: Denies smoking. Denies smoking marijuana recreationally. Denies alcohol intake. Denies illicit drug use. Endorses coffee consumption, 8 oz per day.

Travel: Denies recent travel  

Diet: Admits to a well balanced diet, mainly consisting of whole grains, fruits, vegetables, seafood.

Exercise: Admits to regular exercise daily, plays volleyball recreationally.

Safety measures: Admits to using seatbelt in moving vehicles. 

Sexual history: Denies ever being sexually active. Denies history of STIs.

 

Review of Systems:

General – Denies weight loss, fever, malaise, weight change, or night sweats.

Skin, hair, nails – Denies pain, pruritus, discoloration, excessive sweating, skin changes, and hair changes.

Head – Denies headache, dizziness, trauma, fainting, and Hx of vertigo.

Eyes – Denies discharge, diplopia, eye pain, visual changes, and photophobia. Last eye exam: 3 months ago.

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids. 

Nose/Sinuses – Denies sinus pressure, epistaxis, nasal congestion, discharge, swelling.  

Mouth/Throat – Denies dysphagia, sore throat, hoarseness, cough. Last dental exam: 3 months ago.

Neck – Denies pain with movement, stiffness, swollen glands and trouble swallowing.  

Breasts – Denies skin changes, lumps, nipple discharge. 

Pulmonary System – Denies cough, SOB, DOE, wheezing, hemoptysis or cyanosis. 

Cardiovascular System – Denies chest pain, palpitations, edema. Last EKG: never.

Gastrointestinal System – Reports left lower abdominal pain, diarrhea, vomiting. Denies loss of appetite, hemorrhoids, constipation, rectal bleeding. 

Genitourinary System – Denies flank pain, frequency, oliguria, urgency, nocturia, incontinence.

Sexual History – Denies being currently sexually active. Denies history of STIs. 

Nervous – Denies dizziness, sensory disturbances, paresthesia, or changes in cognition/mental status. 

Musculoskeletal system – Denies swelling/stiffness, joint pain, muscle soreness, reduced mobility. Denies tenderness to palpation and erythema. 

Peripheral vascular system – Denies pins and needles, edema, calf pain, varicosities, cyanosis. 

Hematological System – Denies Hx of DVT/PE, lymph node enlargement, blood transfusions, anemia, clotting.

Endocrine system – Denies diabetes, heat or cold intolerance, excessive hunger/thirst.

Psychiatric – Denies changes in mood, suicidal ideations, irritability, and changes in eating habits.

 

Physical 

General: Well groomed female, appearing as her stated age of 21 years, with small build. She appears awake, alert, oriented to person, place, time and situation. She is cooperative and appears to be a reliable source of information. She appears in distress on the bed in fetal position, clutching her abdomen. 

Vital Signs: 

BP: Seated – (R) 134/76

R: 26 breaths/min, unlabored 

P: 154 beats/min, regular rhythm

T: 36.6 C (Tympanic)

O2 Sat: 94%, room air 

Height: 5’4 inches     Weight: 125 lbs      BMI:  20.6

 

Skin, Hair, Nails, Head:

Skin: Warm and moist. No discoloration. Good turgor. No tattoos, no masses, no bruises, no ulcerations on upper/lower extremities. No visible scarring. 

Hair: Regular quantity, even distribution. Color is dark brown, and the texture is normal. No visible dandruff or lice.

Nails: No clubbing, pitting, signs of infection. Presence of lunula on all nails. Capillary refill < 2 seconds in upper extremities.

Head: Normocephalic, atraumatic, non-tender to palpation. 

 

Eyes:

Eyes appear symmetrical. Eye lashes are well distributed. No strabismus, lid lag, or ptosis noted. Sclera white with no jaundice, cornea clear with no signs of abrasion or nodules. Conjunctiva is clear with no foreign bodies. 

 

Mouth/Neck/Pharynx

Lips: Pink, moist, no cyanosis or edema. 

Buccal Mucosa: Pink, well hydrated, no masses, ulcerations, or leukoplakia.

Palate: Pink, well hydrated, no scars or ulcerations present.

Teeth: Normal dentition, no dental caries present, no plaque buildup.

Gingivae: Moist, with no bleeding, ulcerations, hyperplasia, or discoloration. 

Tongue: Pink, well papillated. Symmetrical with normal texture. 

Oropharynx: Well hydrated, no exudates, masses, or foreign bodies. Uvula pink, midline elevation, no ulcerations. 

Neck: Trachea midline. No masses, scars or pulsations noted. Non-tender to palpation.

 

Thorax/Lungs

Clear to auscultation. Chest was symmetrical with no signs of deformities or trauma. Respirations were unlabored and no accessory muscle use was noted. No tenderness to palpation.

 

Heart

Tachycardia, regular rhythm. Distinct S1/S2 with no murmurs, splitting, friction rubs, or S3/S4 appreciated. Carotid pulses are 2+ bilaterally, no bruits present. 

 

Abdomen

Normoactive bowel sounds in all four quadrants with no bruits or pulsations appreciated. Abdomen is soft, symmetrical, and nondistended. No ecchymosis. Negative McBurney’s point tenderness. No rebound. Mild guarding, mild CVA tenderness, exquisitely tender to palpation of LLQ. 

Neuro Exam 

Mental Status: A&O x3, cooperative, thoughts & speech coherent.

 

Differential Diagnosis

• Ovarian torsion

• Ruptured ovarian cyst

• Diverticulitis 

• Nephrolithiasis 

 

Assessment

A 21 year old female with no PMHx complains of left lower quadrant abdominal pain, accompanied with two episodes of nonbloody, nonbilious vomiting and two episodes of diarrhea. Patient is afebrile and non-toxic. She appears in discomfort and physical exam demonstrates mild guarding, mild CVA tenderness, and exquisite tenderness to palpation of LLQ. Will obtain labs/imaging. 

 

Labs/Imaging 

• CBC, CMP, Hepatic function panel, Lipase, Coags, T&S, Hcg
• Transabdominal US pelvis

 

Results

• All labs WNL
• Pregnancy test: negative 
• Transabdominal US pelvis 
  • Impression: suggestion of 9 cm cystic versus loculated collection anterior to the uterus and superior to the urinary bladder, partially visualized. CT recommended.
• CT abdomen and pelvis with IV contrast obtained 
  • Impression: 10.3 cm anterior pelvic cystic lesion. Consider further characterization with pelvic protocol MRI if clinically warranted; trace pelvic free fluid.

 

Plan

• Lactated Ringers Bolus 1000mL for rehydration
• Famotidine 20 mg injection
• Zofran 4 mg injection
• Maalox oral suspension 30mL
• Morphine 2 mg for pain control
• Ob/gyn and Surgery consult for possible cystectomy 

 

Patient Education

• An ovarian cyst is a fluid filled sac that forms on or inside an ovary, often causing little to no symptoms. 
• Treatment options may include watchful waiting, medication, or surgery, depending on the size, type, and symptoms of the cyst.
• Given that the cystic lesion is >10 cm and is causing severe pain, this will warrant surgical exploration.