tokens: Admission Date : 2009-03-27 Discharge Date : 2009-04-03 Date of Birth : 1960-03-06 Sex : F Service : GYNECOLOGY HISTORY OF PRESENT ILLNESS : The patient is a 49-year-old gravida III , para II , who was sent from her primary care physician 's office secondary to lower abdominal pain . The patient is status post uterine artery embolization on 2009-01-07 secondary to fibroids . She has had continuing vaginal discharge , and was diagnosed with bacterial vaginosis one day prior to admission , and was given a prescription for Flagyl . She noted increasing abdominal pain two days prior to admission , which became more severe on the day prior to admission . She went to her primary care physician 's office on the day of admission complaining of abdominal pain , which she stated was constant but intermittently sharper at times . The location was variable . She also complained of some loose stools on the day of admission , no nausea or vomiting . Her temperature was 100.4 in the office , and she had no chills . She was sent for a CT scan of her abdomen , which revealed fluid and question of gas in the endometrial cavity , and she was sent to Pinewood , Norfolk for treatment and admission . PAST OBSTETRICAL HISTORY : Cesarean section x 2 , spontaneous abortion x 1 . PAST GYNECOLOGIC HISTORY : Last menstrual period 2009-02-21 . Some spotting on the day prior to admission , but not a normal period . Periods regular . Lupron x three months prior to embolization . Fibroid uterus status post embolization on 2009-01-07 . Dilatation and curettage x 1 for SAB . History of herpes simplex virus , last outbreak in 2000 . No history of abnormal Pap smears . PAST MEDICAL HISTORY : None . PAST SURGICAL HISTORY : Cesarean section x 2 , dilatation and curettage x 1 , neck fusion after motor vehicle accident , shoulder surgery after motor vehicle accident . MEDICATIONS : Flagyl . ALLERGIES : None . SOCIAL HISTORY : No smoking , alcohol or drugs . PHYSICAL EXAMINATION : Temperature 100.4 , pulse 108 , respirations 20 , blood pressure 110/70 , oxygen saturation 100% on room air . In general , she was in no acute distress . Her abdomen was notable for voluntary guarding but no involuntary guarding or rebound , mild right lower quadrant tenderness greater than left lower quadrant , nondistended . Her pelvic examination was notable for some brownish discharge . Her uterus and adnexa were difficult to assess secondary to voluntary tensing of her abdomen . ASSESSMENT : This is a 49-year-old gravida III , para II , status post uterine artery embolization on 2009-01-07 due to uterine fibroids , with continued abdominal pain and CT scan revealing fluid and gas in the endometrial cavity . HOSPITAL COURSE : The patient was admitted and was initially started on intravenous ampicillin , gentamicin and clindamycin . Her initial white blood cell count was 11.3 , with a normal differential . Her sedimentation rate was elevated at 110 . Her electrolytes were within normal limits . She was maintained on intravenous antibiotics . On hospital day number three , her blood cultures came back positive in the anaerobic culture for gram-positive cocci in pairs and clusters . Further identification revealed staphylococcus coag-negative , which was sensitive to gentamicin and clindamycin . She was continued on her antibiotics , and was afebrile until hospital day number five , when she had a temperature spike to 102.3 . Repeat blood cultures were sent . Her white blood cell count was 12.8 , with a normal differential . At this time , an Infectious Disease consult was obtained , and the recommendation was to discontinue the ampicillin , gentamicin and clindamycin , and start her on intravenous Unasyn . She underwent a pelvic ultrasound and an abdomen and pelvis CT , which revealed continued air in the endometrial cavity vs. in the fundal fibroid . Discussion was had at this time with the patient regarding whether or not this represented an infected abscess vs. post-surgical change . Extensive discussion was held , and second opinion was obtained regarding the need for possible drainage of the abscess vs. hysterectomy . The patient requested an outside second opinion , as she was reluctant to undergo hysterectomy at this time . She was discharged to home on hospital day number eight , on oral antibiotics . The patient was to have a repeat CT scan in one week . She was also to obtain a second opinion regarding the question of possible surgical management . Claude U Bolanos , M.D. 95-182 Dictated By : William MP Lajoie , M.D. MEDQUIST36 D : 2009-04-02 22:09 T : 2009-04-03 01:26 JOB #: 61261 Signed electronically by : DR. Suzanne Simpson on : FRI 2009-04-24 12:48 PM ( End of Report )