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HISTORY AND PHYSICAL EXAMINATION or EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: Brenda C. Seggermen
Patient ID: 903321
Date of Admission/Date of Arrival: 3/27/----
Admitting/Attending Physician: Alex McClure, MD
Admitting Diagnosis: Ectopic pregnancy
CHIEF COMPLAINT: The patient was admitting to the emergency room this morning complaining of 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's been sexual active and using no birth control.
GYNECOLOGY HISTORY: Patient is gravida 2, para, 1, abortus 1 her only child is a 15-year-old daughter that lives in Texas with her grandmother.
PAST CLINICAL: Positive for hepatitis B.
PAST SURGICAL HISTORY: Pilonidal cyst removed in the remote past. Had plastic surgery on her ears has a child.
SOCIAL HISTORY: Married has one daughter; patient works has a substitute teacher. Smokes one pack of cigarette on a daily basis. Denies EtOH. Smoke marijuana last night. No IV drug abuse.
(Continued
ALLERGIES: TETANUS.
Medication: None.
(Continued)
EMERGENCY SERVICES ADMISSION REPORT
Patient Name: Brenda C. Seggermen
Patient ID: 903321
Date of Admission: 3/27/----
Page 2
REVIEW SYSTEM: Patient complains of lower abdominal pain for the past week that apparently got much worse last night and by this morning wasn't unbearable she also having some nausea and vomiting. Denied hematemesis, hematochezia and melena. She has had vaginal spotting over past month with questionable vaginal discharge as well.
Denied urinal frequency urgency and hematuria. Denied. Review of system is otherwise essentially negative.
PHYSICAL EXAMINATION: Vital signs shows temperature at 97 degree, pulse 53, respiration 22, blood pressure 108/60 GENERAL: physical exam reveals a well-develop, well-nourish 35 year
Patient Name: Brenda C. Seggermen
Patient ID: 903321
Date of Admission/Date of Arrival: 3/27/----
Admitting/Attending Physician: Alex McClure, MD
Admitting Diagnosis: Ectopic pregnancy
CHIEF COMPLAINT: The patient was admitting to the emergency room this morning complaining of 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's been sexual active and using no birth control.
GYNECOLOGY HISTORY: Patient is gravida 2, para, 1, abortus 1 her only child is a 15-year-old daughter that lives in Texas with her grandmother.
PAST CLINICAL: Positive for hepatitis B.
PAST SURGICAL HISTORY: Pilonidal cyst removed in the remote past. Had plastic surgery on her ears has a child.
SOCIAL HISTORY: Married has one daughter; patient works has a substitute teacher. Smokes one pack of cigarette on a daily basis. Denies EtOH. Smoke marijuana last night. No IV drug abuse.
(Continued
ALLERGIES: TETANUS.
Medication: None.
(Continued)
EMERGENCY SERVICES ADMISSION REPORT
Patient Name: Brenda C. Seggermen
Patient ID: 903321
Date of Admission: 3/27/----
Page 2
REVIEW SYSTEM: Patient complains of lower abdominal pain for the past week that apparently got much worse last night and by this morning wasn't unbearable she also having some nausea and vomiting. Denied hematemesis, hematochezia and melena. She has had vaginal spotting over past month with questionable vaginal discharge as well.
Denied urinal frequency urgency and hematuria. Denied. Review of system is otherwise essentially negative.
PHYSICAL EXAMINATION: Vital signs shows temperature at 97 degree, pulse 53, respiration 22, blood pressure 108/60 GENERAL: physical exam reveals a well-develop, well-nourish 35 year