Summary:
- The patient, a 32-year-old female, was admitted for severe abdominal pain and heavy bleeding. She is currently receiving inpatient care for suspected ectopic pregnancy. Progress includes stabilization of vital signs and pain management.
- Key strengths include a supportive family and a positive attitude towards recovery. Challenges involve managing anxiety related to the diagnosis. Treatment goals focus on resolving the ectopic pregnancy and ensuring future reproductive health.
Chief Complaint:
- Severe abdominal pain and heavy vaginal bleeding.
History of Present Illness (HPI):
- The patient experienced sudden onset of severe abdominal pain and heavy bleeding two days ago. Symptoms have progressively worsened, leading to her admission. She reports no recent life events or stressors but has a history of irregular menstrual cycles. Prior to admission, she attempted to manage symptoms with over-the-counter pain relief without success.
Psychiatric History:
- No previous psychiatric diagnoses or treatments. No history of self-harm or suicidality.
Medications:
- Current Medications: Ibuprofen 400mg for pain relief.
- Possessed Medications: None brought to the facility.
- Medication Access: No challenges reported.
- Inpatient Medications:
- PRN: Paracetamol 500mg as needed for pain.
- STAT: Methotrexate administered for ectopic pregnancy management.
- Medication Refusal: None reported.
Substance Use:
- Denies use of alcohol, tobacco, or recreational drugs.
Pain History:
- Reports chronic dysmenorrhea but no other chronic pain conditions.
Drug Screen Result:
- Negative for all substances.
Social History:
- Lives with her partner and has a strong family support system. Works as a teacher and is actively involved in community activities.
Family History:
- Mother has a history of endometriosis. No known family history of substance use disorders.
Legal History (Guardianship, Conservatorship, Representation, etc.):
- No legal issues or guardianship concerns.
Trauma/Abuse History:
- No history of physical, emotional, or sexual abuse reported.
Sleep:
- Reports difficulty sleeping due to pain but generally has good sleep quality.
Functioning Status:
- Able to perform activities of daily living independently. Social functioning is intact.
Disposition:
- Patient is anxious but motivated to follow the treatment plan and achieve discharge goals.
Aggression:
- No instances of aggression or hostility observed.
Review of Systems (ROS):
- Anxiety: Reports increased anxiety related to current health condition.
- Depression: Denies symptoms of depression.
Mental Status Exam:
- Appears well-groomed, cooperative, with a mood congruent to the situation. Thought process is logical, with good insight and judgment.
Tests and Scores:
- PHQ-9 score of 3, indicating minimal depression.
Allergies:
- No known drug allergies.
Review of Systems (General ROS):
- Reports occasional headaches but no other systemic complaints.
Physical Exam:
- Abdominal tenderness noted on examination. No other significant findings.
Vital Signs:
- Blood pressure: 120/80 mmHg, Heart rate: 78 bpm, Respiratory rate: 16 breaths/min, Temperature: 36.8°C, O2 saturation: 98% on room air.
Level of Observation and Precautions:
- Regular observation with no specific precautions required.
Physical Safety Risks:
- No physical safety risks identified.
Safety Assessment:
- No suicidality or self-harm risk. Protective factors include strong family support.
Assessment:
- Suspected ectopic pregnancy with associated pain and bleeding. Anxiety related to health condition.
DSM-5-TR Codes:
- None applicable.
Plan:
- Continue methotrexate therapy and monitor hCG levels. Provide supportive care and pain management. Schedule follow-up ultrasound to assess treatment efficacy.
- Treatment Changes: None at this time.
Follow-Up Email:
- Summary of visit outcomes and recommendations will be sent to the patient’s email. Contact information provided for any questions.
Billing Codes:
- ICD-10: O00.1 (Ectopic pregnancy), CPT: 99221 (Initial hospital care).
To-Dos:
- Schedule follow-up ultrasound. Arrange consultation with a fertility specialist post-discharge.
