Hillcrest Medical Case 1

Topics: Blood, Ectopic pregnancy, Surgery Pages: 8 (1461 words) Published: May 11, 2014
HISTORY AND PHYSICAL EXAMINATION
Good morning this is Alex McClure, MD dictating
PATIENT NAME: Brenda c. Seggerman
PATIENT ID: 903321
Date of Admission: 3/27/2012
EMERGENCY ROOM Physical: Alex McClure. MD
Admitting diagnosis: Egtopic pregnancy
Chief Complain: The patient presents in the emergency this morning, complaining of lower 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 she is sexually active and using no birth control. Gynecologic History: Patient is graved to par 1 abortus 1. her only child is a year old 15 year old daughter who lives in Texas that lives with her grandmother. PAST MEDICAL HISTORY: Positive for hepatitis B

PAST SURGICAL HISTORY: Pilonidal cyst removed in the remote past, has plastic surgery on her ears 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: Tetanus

MEDICATION: None
REVIEW OF SYSTEMS: Patient complains of lower abdominal pain for the past week. Apparently got much worse last night, and by this morning wasn’t tolerable. She is also having some nausea and vomiting, denies hematemesis and mel?? She has had vaginal spotting over the past month with questionable vaginal discharge as well. denies the frequency, urgency and hematuria and denies arthralgia. Review of systems is otherwise essentially negative. PHYSICAL EXAM: 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 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 andexal are more than tender than the right. VAGINAL: The cervix is closed. 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 so the speculum was withdrawn.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. NUEROLOGICAL-in tact urea x3, no nuerologica defictest. DIAGNOSTIC: Dr. on admission hemoglobin 12.8 grams, hemaocrit is 36.6%. urine analysis is essentially negative. beta hcg is positive wit 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 25mg and Phenergan 25mg iv for the pain after her report was obtained. she was also given Claforan 1 gram iv, I paged Dr. Gerald GYN, physician as soon as they received the ultrasound report at approximately 10 am he was not in his north Miami office. I paged the south Miami office and reached Dr. Gerards office at approximately 10:15am. his office personnel 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. The patient received and iv of lactated ringer's upon the arrival in the emergency room. This was normal saline while we were awaiting Dr. Vonbecks arrival. The surgical procedure was explained the patient and her husband all the risk and benefits were discussed. Then assessing in immediate surgery and informed consent was signed. no old records are available for review. Dr McClure end dictation.

Rosemary Bumbak dictating a
OPERATIVE REPORT
Patient Name: Brenda C. Seggerman
Patient ID: 903321
Date of Admission: 03/27/2012
Date of Surgery: 03/27/2012
Surgeon: Rosemary Bumbak, MD
Assistant:...
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