ADMISSION DATE: August 14, 2006

DISCHARGE DATE: August 15, 2006

HISTORY OF PRESENT ILLNESS: This is a 22-year-old white female, nulligravida, who was admitted to the hospital on August 14, 2006 with fever of 103°, left lower quadrant pain, vaginal discharge, constipation, and a tender left adnexal mass. She had a recent past history of anemia and pneumonia for which she was admitted to a community hospital. Her family history was unremarkable except for anemia in her mother. The left lower quadrant pain had started 2 weeks prior. She has no history of OCP intake.

PHYSICAL EXAMINATION: She is a well-developed, well-nourished female who appears in mild distress. HEENT: Normal. Lungs are clear to auscultation and percussion. Cardiac exam shows normal sinus rhythm. Her abdomen was mildly distended, tender, especially in the lower left quadrant. On pelvic examination her cervix was tender on motion, and the uterus was of normal size, retroverted, and fixed. There was a tender cystic mass about 3-4 cm in the left adnexa. Rectal examination was negative.

ADMITTING DIAGNOSIS:
1. Recent history of anemia.
2. Pelvic inflammatory disease (PID).
3. Rule out ectopic pregnancy.

LABORATORY DATA: Hemoglobin 8.3, Hematocrit 25.5, WBC 5200, sed rate 45 mm. Urinalysis was normal. Electrolytes were normal. SMA-12 was normal. Liver function tests were normal. Chest x-ray was negative, 2-hour UCG was negative.

TREATMENT COURSE: On admission, she was started on kanamycin 0.5 gm IM b.i.d. and Cefuroxime 1000 mg every six hours IV, and over the next day the patient's condition improved. Her pain decreased and temperature came down to normal. The pregnancy test was negative. She was then discharged on August 15, 2006, in good condition. She will be seen in the office in one week. She was advised pelvic ultrasound and referred to Ob-Gyn.

 About Us/Mission/Strengths/Quality/MT Job/Rates/Free Trial/Contact