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 stated that she is sexually active and using no birth control.
GYNECOLOGIC 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 1 daughter; patient works as a substitute teacher. Smokes 1 pack of cigaretts on a daily basis. Denies EtOH. Smoked marijuana last night. No IV drug abuse.
ALLERGIES: TETANUS
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 ueinary frequency, urgency, and hematuria. Denies arthralgias. Review of systems is otherwise essentially negative.
PHYSICAL EXAMINATION: Vital signs show temperature 97 degrees, 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. EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: Brenda C. Seggerman
Patient ID:903321
Date of Admission 3/27/2012
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HEENTare 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 her lowed abdominal area.Fundus was not palpable above the pubic area. Left adnexa are more tender than the right. Viginal exam: The cervix is closed. A moderate amount of mucopuruent vaginal discharge is noted. The patient would not allow me to perform a bimanual examination due to her pain, so the speculum was withdrawn. Extremities: No clot, no edema. Neurologic exam: Intact, oriented x3. No neurologic deficits.
DIAGNOSTIC DATA: Admissions hemoglobin 12.8g, hematocrit 36.6%. Urinalysis is essentially negative. Beta-hCG is positive with a WBC count of 23,278.
RADIOLOGY: Pelvic ultrasound shows a 7week 4-day-old viable ectopic pregnancy pre Radiology.
The patient was given Demerol 25mg and Phenergan 25 mg IV for the pain after her report was obtained. She was also given Claforan 1 g IV. I paged Dr. Gerard, patient’s GYN physicial, as soon as I recived the ultrasound report at approximately 10 a.m. His office personnel advised me that he is not on call. Dr. Bumbak is on call. I spoke with Dr. Bumbak at approximately 10:25 a.m., and she will be here to take the patient to the operating room.
ADMITING DIAGNOSIS: Left ectopic first-trimester pregency.
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 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 immediate surgery, and informed consent was signed. No old records are available for review.
__________________________
Alex McClure, MD
AM:AB
D:03/27/2012
T:03/27/2012