History and Physical Examination or Emergency Department Treatmen...

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History and Physical Examination or Emergency Department Treatment Record: Brenda C. Seggerman

By | Feb. 2012
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HISTORY AND PHYSICAL EXAMINATION
or EMERGENCY DEPARTMENT TREATMENT RECORD

Patient Name: Brenda C. Seggerman

Patient ID: 903321

Date of Admission/Date of Arrival: 00/00/0000

Admitting/Attending Physician: Alex McClure, MD

Admitting Diagnosis: Ectopic pregnancy

Chief Complaint: Lower abdominal pain.

HISTORY OF PRESENT ILLNESS: The patients 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, para 1, 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: Pilonidal cyst removed in the remote past. Had plastic surgery on her ears as a child.

SOCIAL HISTORY: Married, 1 daughter. Patient 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: Patients 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 arthralgia. Review of systems is otherwise essentially negative.

PHYSICAL EXAMINATION: Vital signs show, T 97, P 53, R 22, BP 108/60.

GENERAL: A 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. HEENT: are unremarkable except for poor dentation. NECK: Soft and supple. CHEST: Lungs are clear in HISTORY AND PHYSICAL EXAMINATION

or EMERGENCY...