Subjective:
HPI:
53-year-old African American female who presents to the emergency department with c/o heavy vaginal bleeding for four days. At this time, the patient is soaking about one pad per hour and passing some clots. She is perimenopausal and has been menstruating every 6 months for the last two years, usually lasting 7-8 days with variable flow. When this vaginal bleeding started she thought it was her menses, but flow has steadily increased with palm-sized clots reported yesterday. Yesterday, she also began to experience mild lightheadedness and shortness of breath with exertion that resolves with rest. Today, she reports the bleeding is brighter red in color and the clots appear larger. She is not currently sexually active, does …show more content…
•Neuro: Oriented with steady gait and clear speech. No focal deficits appreciated.
•HEENT: PERRL 3+ bilaterally; bilateral nasal passages, mucus membranes and conjunctiva pink and moist. No thyroid enlargement or nodules.
•Cardiac: Regular rate and rhythm, S1 S2 noted, no murmurs.
•Respiratory: Respiration rate and depth appropriate, chest expansion symmetrical, bilateral lungs clear to auscultation anteriorly and posteriorly. No use of accessory muscles.
•Abdomen: Soft, non-tender. No rebound tenderness, guarding or masses. Bowel sounds active x4 quadrants. No bladder distention appreciated.
•GU: External skin and labia are dark pink. Internal vaginal mucosa pink and moist. No lesions, rashes or signs of trauma noted. Multiparous cervix pink and smooth, steady ooze of dark red blood noted from cervical os and small clots (roughly half-dollar sized and smaller) noted in vaginal vault. No cervical motion tenderness. Uterus slightly enlarged and irregular
HPI:
53-year-old African American female who presents to the emergency department with c/o heavy vaginal bleeding for four days. At this time, the patient is soaking about one pad per hour and passing some clots. She is perimenopausal and has been menstruating every 6 months for the last two years, usually lasting 7-8 days with variable flow. When this vaginal bleeding started she thought it was her menses, but flow has steadily increased with palm-sized clots reported yesterday. Yesterday, she also began to experience mild lightheadedness and shortness of breath with exertion that resolves with rest. Today, she reports the bleeding is brighter red in color and the clots appear larger. She is not currently sexually active, does …show more content…
•Neuro: Oriented with steady gait and clear speech. No focal deficits appreciated.
•HEENT: PERRL 3+ bilaterally; bilateral nasal passages, mucus membranes and conjunctiva pink and moist. No thyroid enlargement or nodules.
•Cardiac: Regular rate and rhythm, S1 S2 noted, no murmurs.
•Respiratory: Respiration rate and depth appropriate, chest expansion symmetrical, bilateral lungs clear to auscultation anteriorly and posteriorly. No use of accessory muscles.
•Abdomen: Soft, non-tender. No rebound tenderness, guarding or masses. Bowel sounds active x4 quadrants. No bladder distention appreciated.
•GU: External skin and labia are dark pink. Internal vaginal mucosa pink and moist. No lesions, rashes or signs of trauma noted. Multiparous cervix pink and smooth, steady ooze of dark red blood noted from cervical os and small clots (roughly half-dollar sized and smaller) noted in vaginal vault. No cervical motion tenderness. Uterus slightly enlarged and irregular