HISTORY AND PHYSICAL EXAMINATION
OR EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: Brenda C. Seggerman
Patient ID: 903321
Date of Admission/Date of Arrival: 03/27/----
Admitting/ Attending Physician: Alex McClure, MD
Admitting Diagnosis: ectopic pregnancy
Chief Complaint: The patient presents to the emergency room this morning complaining of lower abdominal pain. HISTORY OF PRESENT ILLNESS: The patient states that she has been having vaginal bleeding, more like spotting, over the past month. She denies the chance of pregnancy. Although, she states that she is sexually active and using no birth control. GYNOCOLOGIC HISTORY: Patient is gravida 2, para 1, abortus 1. Her only child is a 15 year old daughter, who lives in Texas with grandmother. PAST MEDICAL HISTORY: Positive for Hepatitis B.
PAST SURGICAL HISTORY: Pilonidal cyst removed in the remote past, had plastic surgery on her ears as a child. SOCIAL HISTORY: Married, has one daughter. Patient works as a substitute teacher. Smokes one pack of cigarettes on a daily basis. Denies EtOH. Smoked marijuana last night. No IV drug abuse. ALLERGIES: cognes
REVIEW OF SYSTEMS: Patient complains of lower abdominal pain for the past week, that apparently got much worse last night and by this morning was intolerable. She is also having some nausea and vomiting. Denies hematemesis, hematochezia, and melena. She has had vaginal spotting over the past month, with questionable vaginal discharge as well. Denies urinary frequency, urgency, and hematuria. Denies arthralgias. Review of systems is otherwise essentially negative. PHYSICAL EXAMINATION: Vital signs show temperature at 97 degrees Fahrenheit, pulse 53, respirations 22, blood pressure 108/60. GENERAL: Physical exam reveals a well-developed, well-nourished, 35 year old, white female in a moderate amount of distress at the time of the examination. HEEMT are unremarkable, except for poor (continued) HISTORY AND...
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