Summary書き
今日はやる気のあるAttendingにあたり、「じゃ、今からこの患者のSummaryを１時間で書いて持ってきて」と言われました。
１時間って、長そうに感じますが、患者の前のカルテをみて、問診して、身体診察して…とやっていると、あっという間に30分はすぎて行くので、残った30分弱で、WORDにダーッと書いて持ってきました。下に貼りました…
Feedbackは…HistoryとExamはGreatだから、もっとAssessment and Planをしっかり考えてpresenしなさい。“More Oriented"なものにしなさい…ということでした。確かに…どの疾患が可能性が低くて、その理由は何なのか？とか、そういうのが甘いですね。
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40yo F
CC: Pelvic pain
HPI: 40yo F with PMHx of hysterectomy, 40yo F with PMHx of hysterectomy, cholesystectomy, depression and IBS present in ED for bilateral pelvic pain which started 2 wks ago. Pain is 6/10, constant and described as “sharp”. Also since 4 days ago, she feels more fullness on lower abdomen and nausy. Has had bowel movement every day since a week ago till 3 days ago, which was unusual for her who had constipation (1ce a week) in base. Denies vomiting, black/bloody stool, diarrhea. Denies vaginal discharge/bleeding. Denies dysuria,polyuria or hematuria. Has had vaginal ultrasound 3 days ago by GYN in Towson and told “no evidence of change in ovaries.”
PMH :
Partial Hysterectomy (6yrs ago)
Cholecystectomy (3yrs ago)
Depression
IBS
Hypercholesterolemia
SH : Denies Smoking, EtOH use or illicit drug use. Sexually active with husband.
Meds : Prozac, Xanax, Bethanechol, Promethazine, Amatiza, Kapidex
PE : Vitals : BT 36.7, BP 120/63 HR83 RR 18 SpO2 97
HEENT :
Eyes No jaundice, No anemia.
Cranial nerves : All intact
Lung: Clear on both sides.
Heart : Regular S1S2, no murmur.
Abd : Soft and flat. No guarding or rebounding. Tenderness on pelvic area on both sides, slightly stronger in the left. Hypoactive bowel movement sound on all 4 quadrants. Negative Mcburney/Marphy’s sign. Negative CVA tenderness .
Extremities: MMT 5/5 in all 4 extremities. No swelling on legs.
Labs :
CBC, CMP, UA and Lipase within normal range.
Assessment and Plan :
40yo F with PMHx of hysterectomy, 40yo F with PMHx of hysterectomy, cholesystectomy, depression and IBS present in ED for bilateral pelvic pain.
Most likely is constipation/adynamic ileus according to the history and PE. Possibly pelvic inflammatory disease, early appendicitis, diverticular disease and UTI. Must be ruled out is Small/Large bowel obstruction, ectopic pregnancy. History of multiple abdominal surgeries increase risk of SBO/LBO and diverticular disease.
Plan: The last CAT scan was 2 years ago and since this is a new symptom, we should scan her to rule out LBO/SBO . Since PID is possible, we should perform vaginal exam and culture Gonorrha and Chlamidia. We could add HCG to rule out ectopic pregnancy and D-dimer for clots or embolism in mesenteric /rectal arteries.
In summary, with the normal lab results, it is most likely to be a constipation/ IBS/adynamic ileus. However, we should perform abdominal CT and vaginal exam to rule out critical conditions.
