OB-GYN Study

DISCHARGE SUMMARY

ADMITTING DIAGNOSIS

Pelvic inflammatory disease, rule out appendiceal abscess.

DISCHARGE DIAGNOSIS

Pelvic inflammatory disease, improved.

OPERATIONS

None.

COMPLICATIONS

None.

BRIEF HISTORY AND PHYSICAL

This patient is a 29-year-old gravida 2, para 2 woman who has been having pelvic pain for 3 days prior to admission.  She had been seen in my office and found to have a tender uterus, but with no Trichomonas and no yeast, no fever, and normal white count.  Serum pregnancy test was negative, and patient was seen in the emergency room and subsequently admitted for increasing pelvic pain.  A Chlamydia enzyme test was reported as negative prior to admission.

LABORATORY AND COURSE IN THE HOSPITAL

CBC on admission showed an 8600 white count, 67 segs, and no bands.  Subsequent CBCs continued to show relatively normal white counts of 6300 and 6500, again with no distinct left shift.  A pelvic sonogram revealed a retroverted uterus with normal ovaries and an edematous left fallopian tube which would be consistent with pelvic inflammatory disease.  An abdominal sonogram is generally normal, but the head of the pancreas was unable to be evaluated due to bowel gas.

Since admission, patient has been treated with Flagyl 500 mg every 8 hours intravenously and 1000 mg of Ancef every 8 hours.  She has been treated with Vicodin and/or Darvocet-N 100 for pain.  Stadol injections have been given at times, Compazine for nausea, Colace to soften stools, and milk of magnesia to move bowels.  She has also been given Fleet enemas at times when had difficulty passing stools.

Although the pain is essentially gone and appetite is satisfactory, patient continues to experience difficulty voiding.  Urinalysis showed 10 to 20 epithelial cells, but no white cells and no bacteria.  Gram stain from the cervix revealed rare diplococci which were all extracellular.  A culture failed to reveal any gonorrhea.

Patient will be discharged at the present time on a normal diet and encouraged to drink fluids.  She is to report any difficulty voiding.  I will ask patient to make an appointment in my office in 48 hours for followup examination to see if she can be released for work the following Monday.

FOOTNOTE

Line 44 (Page 1).  Alternative:  The physician uses the possessive Fleet’s, which is acceptable, but the product is officially listed as Fleet enema.

Line 49 (Page 1).  Alternative:  10-20.