H and P Brenda Seggerman

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HISTORY AND PHYSICAL EXAMINATION

Patient Name: Brenda C Seggerman

Patient ID: 903321

Date of Admission/Date of Arrival: 03/27/----

Admitting/Attending Physician: Alex McClure, MD Emergency Department Physician

Admitting Diagnosis: Left ectopic 1st trimester pregnancy

Chief Complaint: Patient presents to emergency room 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 that she is sexual active and using no birth control.

GYNECOLOGICAL 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. Has one daughter. Patient works as a substitute teacher. Smokes 1 pack of cigarettes on a daily bases. 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 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 arthralgias. Review of systems is otherwise essentially negative.

PHYSICAL EXAMINATION: VITAL SIGNS: show temperature 97 F; Pulse 53; Respirations 22; Blood Pressure 108/60. GENERAL 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. HEEMT: are unremarkable except for poor dentation. NECK: is soft and

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