Identifying Data: 

Full Name: XX

Address: XX

Date of Birth: XX

Date & Time: 03/22/24 11AM

Location: New York Presbyterian Hospital, Queens

Religion: Christian 

Source of Information: Self

Reliability: Reliable 

Source of Referral: Self 

Mode of Transportation: Self 

 

Chief Complaint: “bump on genital area” x 1 week 

History of Present Illness: 

A 24 year old female with no PMHx presents to the ER complaining of a swollen lump on her left labia majora that appeared a week ago. She reports that it was smaller earlier in the week but is now larger, more erythematous, and very tender to touch. She explains that she shaves the area daily and frequently experiences ingrown hairs. As per patient, this started out as an ingrown hair but has now progressed in size, notable erythema, and pain. Endorses a subjective fever. She reports that the pain is constant, rated a 9/10 and is exacerbated with walking and sitting, which makes it difficult for her to work. She has not taken any medications to alleviate the pain. She denies pruritus, nausea, abdominal pain, dysuria, history of STDs, previous episodes, abnormal vaginal discharge. Denies sick contacts and recent travel. 

Past Medical History: 

Present Illnesses – None

Immunizations: Fully up to date

Childhood illnesses: None 

 

Past Hospitalizations: 

None

 

Past Surgical History:  

None

 

Medications: 

None

 

Allergies: 

No known drug allergies

Food allergies: Shrimp

 

Family History: 

Mother – alive with DM

Father – alive with HTN

2 brothers – alive & well.

Maternal Grandmother – alive with DM & HTN

Maternal Grandfather –  alive with HTN and A.Fib

Paternal Grandmother –  alive with HTN 

Paternal Grandfather –  alive with HTN

 

Social History: 

Ms. PO is a female living in her house with her mother, father, and two brothers. She is currently working as a nurse. 

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, walks and weight lifts with her friends. 

Safety measures: Admits to using seatbelt in moving vehicles. 

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

 

Review of Systems:

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

Skin, hair, nails – Endorses pain to the genital area. Denies pruritus, discoloration, excessive sweating.

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

Eyes – Denies discharge, diplopia, eye pain, visual changes, and photophobia. Last eye exam: 6 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: 6 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 – Denies 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 24 years, with medium build. She appears awake, alert, oriented to person, place, time and situation. She is cooperative and appears to be a reliable source of information.

Vital Signs: 

BP: Seated – (R) 112/75

R: 16 breaths/min, unlabored 

P: 98 beats/min, regular rhythm

T: 99.1 (Tympanic)

O2 Sat: 100%, room air 

Height: 5’5 inches     Weight: 140 lbs      BMI:  23.3

 

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

Regular rate and 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. No rebound, guarding, or tenderness. 

 

Genitalia (with PA as a chaperone) 

Large, fluctuant swelling measuring approximately 4 cm in diameter on the left labia majora, proximal to the Bartholin glands. Erythematous and warm to the touch with significant tenderness to palpation. No discharge, crusting, pus. No crepitus or skin necrosis. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix pink, without lesions or discharge. No cervical motion tenderness. Uterus non-tender and not enlarged. No adnexal tenderness or masses noted. 

 

Neuro Exam 

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

 

Differential Diagnosis

• Bartholin abscess

• Bartholin cyst 

• Inclusion cyst on vulva

 

Assessment

A 24 year old female with no PMHx complains of an area of swelling and pain to the left labia majora. She reports a subjective fever and pain with movement and daily activities. Physical exam demonstrates a 4 cm large, fluctuant, warm, erythematous swelling on the left labia majora with significant tenderness to palpation. Will obtain labs and consult ob/gyn. 

 

Labs/Imaging 

• CBC, CMP, Hepatic function panel, Coags, T&S, Hcg, urine G/C, blood culture

 

Results

• CBC demonstrates mild leukocytosis (11.5k), remainder of labs WNL.
• Pregnancy test: negative 

 

Plan

• Consult ob/gyn for incision & drainage of abscess with local anesthesia and placement of Word catheter
• Obtain wound culture and sensitivity
• For 7 days: Cephalexin 500 mg orally, 4 times daily + Metronidazole 500 mg orally, 3 times daily
• Catheter removal in 4 weeks

 

Patient Education

• Engage in proper wound care, keep the area clean and dry, use sitz baths and mild analgesics to treat pain.
• Return to the ER if the catheter falls out, worsening signs of infection, such as increasing redness, swelling, or fever.