istory of Present Problem:

Jean Simmons is a 22-year-old-

college student who presents to the
emergency department with RLQ
abdominal pain and intermittent
vaginal bleeding. Her pain started
suddenly two hours ago and has
been severe and persistent. She
noticed a small amount of bright
red
vaginal bleeding in the last hour.
Jean has irregular cycles and it has
been six weeks since her last
menses, which is not unusual for
her.
She admits to feeling more
fatigued the last couple weeks with
intermittent nausea. Jean is 5’ 8”
and weighs 74 kg (163 lb
istory of Present Problem:
Jean Simmons is a 22-year-old-
college student who presents to the
emergency department with RLQ
abdominal pain and intermittent
vaginal bleeding. Her pain started
suddenly two hours ago and has
been severe and persistent. She
noticed a small amount of bright
red
vaginal bleeding in the last hour.
Jean has irregular cycles and it has
been six weeks since her last
menses, which is not unusual for
her.
She admits to feeling more
fatigued the last couple weeks with
intermittent nausea. Jean is 5’ 8”
and weighs 74 kg (163 lb
Jean Simmons is a 22-year-old-
college student who presents to the
emergency department with RLQ
abdominal pain and intermittent
vaginal bleeding. Her pain started
suddenly two hours ago and has
been severe and persistent. She
noticed a small amount of bright
red
vaginal bleeding in the last hour.
Jean has irregular cycles and it has
been six weeks since her last
menses, which is not unusual for
her.
She admits to feeling more
fatigued the last couple weeks with
intermittent nausea. Jean is 5’ 8”
and weighs 74 kg (163 lbs.).
HISTORY OF PRESENT PROBLEM:

Jean Simmons is a 22-year-old-college student who presents to the emergency department with RLQ
abdominal pain and intermittent vaginal bleeding. Her pain started suddenly two hours ago and has
been severe and persistent. She noticed a small amount of bright red vaginal bleeding in the last hour.
Jean has irregular cycles and it has been six weeks since her last menses, which is not unusual for her.
She admits to feeling more fatigued the last couple weeks with intermittent nausea. Jean is 5’ 8” and
weighs 74 kg (163 lbs.).

Personal/Social History:

Jean has been sexually active since the age of 16 and has had three male partners in the last six months.
She insists that they use condoms which she provides. She has a history of an ovarian cyst and was
treated for pelvic inflammatory disease (PID) six months ago.

Current VS: P-Q-R-S-T Pain Assessment (5th VS):

 T: 98.4 F
Provoking/Palliative Movement of any kind/Lying
still in fetal position

(36.9 C)
oral
T: 98.4 F (36.9 C) oral
P: 98 (regular) Quality: Sharp/stabbing

R: 20 (regular) Region/Radiation: RLQ abdomen

BP: 102/52 Severity: 9/10
O2 sat: 98% room air Timing: Constant

CURRENT ASSESSMENT:

General Apperance Appears uncomfortable, body tense

RESP. Breath sounds clear with equal aeration
bilaterally, nonlabored respiratory effor
CARDIAC: Pink, warm and dry, no edema, heart sounds
regular with no abnormal beats,
pulses strong, equal with palpation at
radial/pedal/post-tibial landmar

NEURO: Alert and oriented to person, place, time, and

situation (x4)
GI: Abdomen soft/tender to gentle palpation in RLQ,
bowel sounds audible per
auscultation in all four quadrants

GU/REPRODUCTIVE: Voiding without difficulty, urine clear/yellow,

small amount of red vaginal
bleeding present on maxi pad. Pad is NOT soaked

SKIN: Skin integrity intact

Lab Results:

Complete Blood Count Current: High/Low/WNL? Previous

(CBC:)
WBC (4.5–11.0 mm 3) 8.8 WNL 9.5
Hgb (12–16 g/dL) 9.9 Low 12.8
Platelets (150-450 155 WNL 225
x103/µl)
 Neutrophil % (42–72) 70 WNL 68

Other Labs Current: High/Low/WNL?

Urine pregnancy Positive pregnancy test High
Serum HCG quantitative 9250 High
Rh Factor negative WNL

Radiology Reports: Pelvic Ultrasound

RELEVANT Clinical Significance:

Result

No gestational sac Ectopic pregnancy indicated due to positive

observed. Cannot pregnancy test, elevated
exclude ectopic hCG levels, but no gestational sac observed
pregnancy within the uterus