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. GYNOCOLOGIC HISTORY: Patient is gravida 2, para 1, abortus 1. Her only child is a 15 year old daughter, who lives in Texas with 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 abuse. ALLERGIES: cognes MEDICATIONS: 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 at 97 degrees Fahrenheit, 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 (continued) HISTORY AND PHYSICAL EXAMINATION OR EMERGENCY DEPARTMENT TREATMENT RECORD Patient Name: Brenda C. Seggerman Patient ID: 903321 Date of Admission: 03/27/—- Page 2 dentation. NECK: soft and supple. CHEST: lungs are clear in all fields. HEART: regular rate and rhythm. ABDONMEN: soft with positive tenderness of her lower abdominal area. Fundus was not palpable above the pubic area. Left adnexa are more tender than the right. VAGIONAL EXAM: The cervix is closed. A moderate amount of mucopurulent vaginal discharge is noted.
The patient would not allow me to perform a bimanual examination due to her pain, so the speculum was withdrawn. EXTREMEDIES: No clog, no edema. NEUROLOGIC EXAM: in tacked oriented x3, no neurologic defecates. DIAGNOSTIC DATA: Admission hemoglobin 12. 8 grams, hematocrit 36. 6%, urinalysis is essentially negative. Beta-hCG is positive with a WBC count of 23,278. RADIOLOGY: Pelvic ultrasound shows a 7 week 4 day old viable ectopic pregnancy per radiology. The patient was given Demerol 25 milligrams and Phenergan 25 milligrams IV for the pain after her report was obtained.
She was also given Claforan 1 gram IV. I paged Doctor Gerard, patients GYN physician, as soon as I received the ultrasound report, at approximately 10 a. m. He was not in 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 Bombeck is on call. I spoke with Doctor Bombeck at approximately 10:25 a. m. and she will 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 awaiting Doctor Bombeck’s arrival. The surgical procedure was explained to the patient and her husband. All the risks and benefits were discussed. They understand the necessity for immediate surgery and informed consent was signed. Now all records are available for review. Doctor McClure ending dictation, Thank you! _________________________ Alex McClure, MD AM:xx D: 03/27/—- T: 03/27/—-