History and Physical Examination

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  • Topic: Medical history, Physical examination, Abdominal pain
  • Pages : 2 (323 words )
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  • Published : May 18, 2013
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HISTORY AND PHYSICAL EXAMINATION (H&P)

Patient Name: Brenda Seggerman

Hospital No.: N/A

Room No.: N/A

Date of Admission: 03/27/- - - -

Admitting Physician: Alex Mcclure, MD

Admitting Diagnosis: Ectopic Pregnancy

HISTORY OF PRESENT ILLNESS: The patient states that she has been having vaginal bleeding more like spotting over the past month. The patient denies the chance of pregnancy, although the patient states that she is sexually active and using no birth control.

GYNECOLOGICAL HISTORY: Patient is gravada 2, para 1, abortus 1. The patient’s only child is a 15 year old daughter who lives in Texas with her grandmother.

PAST MEDICAL HISTORY: Patient had a Pilonidal cyst removed. Had plastic surgery on her ear as a child.

SOCIAL HISTORY: Patient is married and has 1 daughter. She works as a substitute teacher. Smokes 1 pack of cigarettes on a daily basis. Denies EtOH. Smoked marijuana last night. No IV drug abuse.

ALLERGIES: Tetanus.

MEDICATIONS: None.

REVIEW OF SYSTEMS: Patient complains of her lower abdominal pain the past week that apparently got much worse last night 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. Patient also denies arthralgias.

REVIEW OF SYSTEMS: Otherwise essentially negative.

PHYSICAL EXAMINATION: Vital signs temperature 97 degrees, pulse 53, respirations 22, blood pressure 108/60.

GENERAL: Physical exam reveals a well-developed, well-nourished 35 year-old white female in a HISTORY AND PHYSICAL EXAMINATION (H&P)

Patient Name: Brenda Seggerman

Patient ID: 903321

Date of Admission: 03/27/- - - -

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