Hillcrest Medical Case 1

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HISTORY AND PHYSICAL EXAMINATION or EMERGENCY DEPARTMENT TREATMENT RECORD

Patient Name: Brenda C. Seggerman

Patient ID: 903321DOB:Age:35Sex: F

Room No.:

Date of Admission/Date of Arrival: 3/27----

Admitting /Attending Physician: Alex McClure M.D.

Admitting Diagnosis: Ectopic Pregnancy

Chief Complaint: The patient presents in 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.

Gynecologic History: Patient is gravida 2, para1, abortus 1. Her only child is a 15 year-old daughter who lives in Texas with her grandmother.

Past Medical History: Positive for Hepatitis B

Past Surgical History: Pilodinal 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 Marihuana last night. No IV drug abuse.

Allergies: TETANUS

Medication: None

HISTORY AND PHYSICAL EXAMINATION
OR EMERGENCY DEPARTMENT TREATMENT RECORD

Patient Name: Brenda C. Seggerman
Patient ID: 903321
Date of Admission: 3/27/----
Page 2

Review Systems: Patients complains of a lower abdominal pain for the past week that apparently got much worse last night and by this morning wasn’t tolerable. 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 Arthralgia. Review of systems is otherwise essentially negative.

Physical Examination: Vital signs show T 97 degrees, P 53, R 22, BP 108/60.

General Physical Exam reveals a well...
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