Case 1 ER Addmission K
HISTORY AND PHYSICAL EXAMINATION OR EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: Brenda Seggerman
Patient ID: 903321
Date of Admission/ Date of Arrival: 03/27/2015
PHYSICAL EXAMINATION: Vital signs show temperature 97 degrees. Pulse 53 respirations 22. Blood pressure 108/60. GENERAL: physical exam revels a well-developed, well-nourished 35-year-old white female is the moderate amount of distress at the time of the examination, HEENT are all remarkable except poor indentation. Neck is soft and supple. CHEST: Lungs are clear in both fields. HEART: Regular rate and rhythm. ABDOMEN: soft but positive tenderness of her lower abdominal area. Fundus was not palpable above the pubic area. Left adnexal are more than tender than the right. VAGINAL EXAM: The cervix is close. A moderate amount of motherapulient vaginal discharge is noted. The patient wouldn’t allow me to perform a bimanual examination due to her pain so the speculum was withdrawn. EXTERMITIES: No clot or edema. NUEROLOGIC EXAM: Intact urea x3, no neurologic deficits. DIAGNOSTIC Dr.: admission hemoglobin 12.8 grams, hematocrit is 36.6%. Urinalysis is essentially negative. Beta hcg is positive with the WBC count of 23,278. RADIOLOGY: pelvic ultrasounds shows a 7 week, 4 day off viable ectopic pregnancy per radiologist. The patient was given Demerol 25 mg and Phenergan 25mg IV for the pain after her report was obtained. She was also given Claforan 1 gram IV. I paged the South Miami office and reached Dr. Gerard’s office at approximately 10:15 am. His office personal advised me that he is not on call, Dr. Vonbeck is on call. I spoke with Dr. Vonbeck at approximately 10:25 am and she will be here to take the patient to the operating room.
ADMITTING DIAGNOSIS: Left Ectopic 1st trimester pregnancy. Disposition: The patient received an IV of lactated ringer’s upon the arrival. The surgical procedure was explained to the patient and husband all the risk and benefits were discussed. Then assessing in
Patient Name: Brenda Seggerman
Patient ID: 903321
Date of Admission/ Date of Arrival: 03/27/2015
PHYSICAL EXAMINATION: Vital signs show temperature 97 degrees. Pulse 53 respirations 22. Blood pressure 108/60. GENERAL: physical exam revels a well-developed, well-nourished 35-year-old white female is the moderate amount of distress at the time of the examination, HEENT are all remarkable except poor indentation. Neck is soft and supple. CHEST: Lungs are clear in both fields. HEART: Regular rate and rhythm. ABDOMEN: soft but positive tenderness of her lower abdominal area. Fundus was not palpable above the pubic area. Left adnexal are more than tender than the right. VAGINAL EXAM: The cervix is close. A moderate amount of motherapulient vaginal discharge is noted. The patient wouldn’t allow me to perform a bimanual examination due to her pain so the speculum was withdrawn. EXTERMITIES: No clot or edema. NUEROLOGIC EXAM: Intact urea x3, no neurologic deficits. DIAGNOSTIC Dr.: admission hemoglobin 12.8 grams, hematocrit is 36.6%. Urinalysis is essentially negative. Beta hcg is positive with the WBC count of 23,278. RADIOLOGY: pelvic ultrasounds shows a 7 week, 4 day off viable ectopic pregnancy per radiologist. The patient was given Demerol 25 mg and Phenergan 25mg IV for the pain after her report was obtained. She was also given Claforan 1 gram IV. I paged the South Miami office and reached Dr. Gerard’s office at approximately 10:15 am. His office personal advised me that he is not on call, Dr. Vonbeck is on call. I spoke with Dr. Vonbeck at approximately 10:25 am and she will be here to take the patient to the operating room.
ADMITTING DIAGNOSIS: Left Ectopic 1st trimester pregnancy. Disposition: The patient received an IV of lactated ringer’s upon the arrival. The surgical procedure was explained to the patient and husband all the risk and benefits were discussed. Then assessing in