S: 21 yo (year old) WF (white female) G2P1001 (Gravida 1, Para 1001 – she has delivered one child at term), with complaint of RLQ (Right Lower Quandrant) Pain for the past month, and more pain during intercourse. The pain is sharp and buring. She has no diarrhea, no constipation. She does c/o (complain of) Pelvic pain for the past 1 year, but supposedly has no history of STD’s (Sexually Transmitted Diseases). Also, she has no N/V/F (nausea/vomiting/fevers).
VSS (Vitals signs Stable), Afebrile
HEENT (Head, Ear, Nose, Throat) – NC/AT – (Normal Cephalic/Atraumatic)
Lungs: CTA B (Clear to Auscultation bilaterally)
ABD (Abdomen): +BS – (positive bowel sounds), TTP (Tender to Palpation), +Rebound,
Pelvic: NEFG (Normal External Female Genitalia), CVX (Cervix) – with discharge, pus and odor; +fullness to pelvis on the right, +CMT (positive Cervical Motion Tenderness), R/V (Recto/Vaginal) – is full.
Ext (Extremities) – No C/C/E (no cyanosis, clubbing, or edema)
A/P: 21 yo WF G2P1001 with most likely CPP (Chronic Pelvic Pain) with possible Appy (appendicititis), Endometriosis, Ovarian Cyst, Ovarian Torsion, or PID (Pelvic Inflammatory Disease).
1. Cultures for STD, GC/CT (Gonorrhea/ Chlamydia)
2. Pelvic US (ultrasound)
3. Dx L/S (Diagnostic Laparoscopy)
4. Doxycycline 100mg po bid (100 milligrams to be taken by mouth twice per day)
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