Chief Complaint: The patient presents to the 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 sexually active and using no birth control. GYNECOLOGY HISTORY: Patient is gravid 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 one pack of cigarettes on a daily basis. Denies EtOH. Smoked marijuana last night. No IV drug abused. ALLERGIES: Tetanus. MEDICATIONS: None. REVIEW OF SYSTEM: Patient complaints 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 HISTORY AND PHYSICAL EXAMINATION OR EMERGENCY DEPARTMENT TREATMENT RECORD Patient Name: Brenda C. Seggerman Patient ID: 903321 Date of Admission: 3/27 Page 2 hematemesis, hematochezia, and melana. She has had vaginal spotting over the past month with questionable vaginal discharge as well. Denies urinary frequency, urgency, and hematuria. Denies arthralgia. 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 dentition. NECK is soft and supple. CHEST: Lungs are clear in all fields. Heart: regular rate and rhythm. ABDOMEN: Soft with positive tenderness of a lower abdominal area. Fundus was not palpable above the pubic area. LEFT ADNEXA: Are more tender than the right. VAGINAL EXAM: The cervix is closed. A moderate amount of mucopurulent vaginal discharge is noted.
The patient would not allowed me to preformed a bimanual examination due to her pain, so the speculum was withdrawn. EXTREMITIES: no clog, No edema. NEUROLOGIC EXAM: Intact, oriented x3, no neurologic deficits. DIAGNOSTIC DATA: Admission: Hemoglobin 12. 8g, Hemotocrit: 36. 6%, Urinalysis is essentially negative. Beta-hCG: is positive with a WBC count of 23,278. RADIOLOGY: Pelvic ultrasound shows a seven-week four day of viable ectopic pregnancy per radiology The patient was giving Demarol 25 mg and Phenegan 25 mg IV for the pain after her report was obtained.
She was also HISTORY AND PHYSICAL EXAMINATION OR EMERGENCY DEPARTMENT TREATMENT RECORD Patient Name: Brenda C. Seggerman Patient ID: 903321 Date of Admission: 3/27 Page 3 giving Claforan 1g IV. I paged Doctor Gerard, patient’s GYN physician as soon as I received the ultrasound report at approximately 10 a. m.. He was not on his North Miami office; I paged the South Miami office, and reached Doctor Gerard’s office at approximately 10:15 a. m. His office personnel advised me that he is not on call.
Doctor Bumbak is on call. I spoke with Dr. Bumbak approximately 10:25 a. m., and she would be here to take the patient to the operating room. ADMITTING DIAGNOSIS: Left ectopic,first trimester pregnancy. DISPOSITION: The patient received an IV of lactated Ringer’s upon arrival at the emergency room. This was switched to normal saline while we were awating waiting Dr. Bumbak’s arrival. The surgical procedure was explained to the patient and her husband. All risks and benefits were discussed. They understand the necessity for immediately surgery and inform consent was sign. No old records are available for review. _________________________ Alex Mcclure, MD AM D:2/07/13 T:2/07/13.