Case Study 1 History and Physical Examination
HISTORY AND PHYSICAL EXAMIATION
OR EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: Brenda C. Seggerman
Patient ID: 903321
Room No.:
Date of Admission/ Date of Arrival: 3/27
Admitting/ Attending Physician: Alex McClure, MD
Admitting Diagnosis: Ectopic Pregnancy
Chief Complaint: Lower Abdominal Pain
HISTORY OF PRESENT ILLNESS: The patient states that she has been having some 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.
GYNOCOLOGIC HISTORY: Patient is gravida 2, para 1, abortus 1 the 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, has 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: None.
TETANUS: None.
MEDICATIONS: None.
REVIEW OF SYSTEMS: Patient complains of a 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 emodocesia and melena. She has had vaginal spotting over the past month with questionable vaginal discharge as well. Denies urinary frequency urgency and hematuria. Denies arthralgias. Review of systems is otherwise essentially negative.
PHYSICAL EXAMINATION: Vital signs show temperature at 97 degrees. Pulse 53. Respirations 22. Blood pressure 108/60.
HISTORY AND PHYSICAL EXAMINATION
OR EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: Brenda C. Seggerman
Patient ID: 903321
Date of Admission 12/01/2014
Page 2
GENERAL: Physical exam reveals a well-developed well-nourished 35 year old white female in a moderate amount of distress at the time of
OR EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: Brenda C. Seggerman
Patient ID: 903321
Room No.:
Date of Admission/ Date of Arrival: 3/27
Admitting/ Attending Physician: Alex McClure, MD
Admitting Diagnosis: Ectopic Pregnancy
Chief Complaint: Lower Abdominal Pain
HISTORY OF PRESENT ILLNESS: The patient states that she has been having some 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.
GYNOCOLOGIC HISTORY: Patient is gravida 2, para 1, abortus 1 the 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, has 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: None.
TETANUS: None.
MEDICATIONS: None.
REVIEW OF SYSTEMS: Patient complains of a 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 emodocesia and melena. She has had vaginal spotting over the past month with questionable vaginal discharge as well. Denies urinary frequency urgency and hematuria. Denies arthralgias. Review of systems is otherwise essentially negative.
PHYSICAL EXAMINATION: Vital signs show temperature at 97 degrees. Pulse 53. Respirations 22. Blood pressure 108/60.
HISTORY AND PHYSICAL EXAMINATION
OR EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: Brenda C. Seggerman
Patient ID: 903321
Date of Admission 12/01/2014
Page 2
GENERAL: Physical exam reveals a well-developed well-nourished 35 year old white female in a moderate amount of distress at the time of