Emergency Department
Patient Case Number: ED34-Tyler, Helena
Patient Name: Helena Tyler | DOB: 05-22-88 | Sex: F
Date of Service: 06-15-XX | Attending Physician: Mitchell Pearson, MD
Reason for Visit: Vaginal bleeding

# History of Present Illness:

This patient is G1 P0, 7w 5d. Yesterday she had some pelvic pain with crampy discomfort and a small amount of vaginal bleeding. Beta hCG was 4000 and an ultrasound showed a fetus but no heartbeat. She said that today her pain gotten much worse. She’s had some active vaginal bleeding and has passed a small amount of tissue. There is no fever, chills, vomiting, or diarrhea. No fall or trauma.

# Medical History: Fibromyalgia Medications: Gabapentin 600mg qd Allergy: Penicillin

# Review of Systems:

The ROS documented in this emergency department record has been reviewed and confirmed by me. Those systems with pertinent positive or negative responses have been documented in the HPI. All other systems are negative or noncontributory.

# Vitals:

Temperature | 98.6°F
Pulse | 68
Respirations | 17
Blood Pressure | 128/70
SpO2 | 98% on room air

# Physical Examination:

# PERRL: EOMs intact. External inspection of ears and nose reveals no acute abnormalities. Examination of oropharynx is normal. Conjunctiva Spink there is no respiratory distress Supple with no masses or tenderness. Thyroid is normal.

# Respiratory: Normal respiratory effort. Auscultation of lungs reveals normal breath sounds.

# Cardiovascular: Heart auscultation reveals RRR and no abnormal sounds or murmurs. Extremities reveal no non-traumatic edema.

# Abdomen: Abdomen is soft with no masses or tenderness. No hepatosplenomegaly. Except for morbid obesity. Pelvic exam showed active bright red vaginal bleeding from an open cervix. There is a small amount of tissue in the vaginal cavity which did appear to be a miscarriage with fetus and placental tissue. Bleeding continued but she remained hemodynamically stable

# ED Course/MDM:

We consulted OB they are admitting the patient for a suction D&C

# Final Impression:

Spontaneous incomplete miscarriage Fibromyalgia

# Electronically Signed By: Mitchell Pearson, MD

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