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. GYNECOLOGIC HISTORY: Patient is gravida 2, para 1, abortus 1. He only child is a 15 year old daughter who lives in Texas with her grandmother. PAST HISTORY: Positive for Hepatitis B. SURGICAL HISTORY: Pilonidal cyst removed in the emote 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: Ketenes MEDICATIONS: None. REVIEW OF SYSTEMS: Patient complains 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 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: temperature 97. 0, pulse 53, respirations 22, blood pressure 108/60. General. (Continued) HISTORY AND PHYSICAL EXAMINATION OR EMERGENCY DEPARTMENT TREATMENT RECORD Patient name: Brenda C. Saggerman Patient ID: Date of Admission: Page 2 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. CHEST: Lungs are clear in all fields. CARDIAC: regular rate and rhythm.
ABDOMEN: soft but positive tenderness of her lower abdominal area. Fundus was not palpable above the pubic area. Left adnexa are more tender than the right. VGINAL 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 So the speculum was withdrawn. EXTREMETIES: No clog, no edema. NEUROLOGIC EXAM: Intact. No neurologic deficits. 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.
READIOLOGY: Pelvic ultrasound shows a 7 week 4 day old viable ectopic pregnancy per radiology. The patient was given Demerol 25 mg and Phenergan 25 mg IV for the pain after her report was obtained. She was also given Claforan 1 gram IV. I paged Dr. Gerard, patients GYN Physician, as soon as I received the ultrasound report at approximately 10 a. m. He was not in in his North Miami office. I paged the South Miami office and reached Dr. Gerard’s office at approximately 10:15 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. 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 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 immediate surgery and informed consent was signed. No old records are available for review. _____________________
Alex McClure, MD RADIOLOGY REPORT OR DIAGNOSTIC IMAGING REPORT Patient Name: Brenad C. Seggerman Patient ID: 903321 Date of Admission: 03/27/2014 Emergency Room Admission: Alex McClure, MD Attending Physician: Donna Harrison, MD Procedure: Trans-vagianal ultrasound Date of Procedure: 03/27/2014 PATIENT HISTORY: Severe left pelvic pain. Rule out ectopic pregnancy. Pregnancy test is positive. FINDINGS: Trans-abdominal imaging demonstrates a uterus with a small amount of fluid within it. There is a pseudodecidual sign. There is a large amount of hemorrhage seen within the left adnexa. No embryo is seen.
The right ovary is unremarkable. Endo-vaginal examination was performed in search of a viable ectopic. One is seen with a crown-rump length of 1. 3 cm corresponding to 7 weeks 4 days. A large amount of free fluid is seen. A pseudo gestational sack is noted within the uterus, which is oblong. IMPRESSION:A left sided ectopic pregnancy is found with a large amount of hemorrhage noted within the left adnexa and extending into the cul-de-sac. The hemorrhage measures 13x6x10 cm. Dr. McClure in the emergency room was notified, who will notify the surgeon, who is on her way to the hospital.
________________________ Donna Harrison, MD C: Rosemary Bumbak, MD, OB-GYN OPERATIVE REPORT Patient Name: Brenda C. Seggerman Patient No. : 903321 Date of Admission: 03/27/2014 Date of Procedure: 03/27/2014 Admitting Physician: Alex McClure, MD Surgeon: Rosemary Bumbak, MD, OB-GYN Assistant: Michael Gerard, DO Preoperative Diagnosis: Left tubule ectopic pregnancy Postoperative Diagnosis: 1. Ruptured left tubule ectopic pregnancy 2. Hemoparitoneum 3. Pelvic adhesions Surgical Procedure: 1. Exploratory laparotomy 2. Partial salpingectomy 3. Evacuation of hemoparitoneum 4. Lysis of adhesions.
Anesthesia: General endotracheal by Dr. Avalon. Specimen Removed: Portion of the left fallopian tube containing the ectopic pregnancy. Estimated Blood Loss: Approximately 1000 ml requiring transfusion of 2 units of O blood. PROCEDURE IN DETAIL: The patient was prepped and draped in the usual manner and placed under adequate general anesthesia. A Pfannenstiel incision was performed and carried through skin and subcutaneous tissue, fascia and the peritoneum. The peritoneal cavity was entered. (Continued) OPERATIVE REPORT Patient Name: Brenda C. Seggerman Patient ID:903321 Date of Procedure: 03/27/2014.
Page 2 The hemoparitoneum was noted, and approximately 500 ml of blood was rapidly evacuated from the pelvic cavities, as were large clots. Following this, the bowel was packed away from the pelvic area with packing laps. A retaining retractor was introduced. The left fallopian tube was noted. A large tubule ectopic pregnancy was noted, affecting the approximately the distal half of the fallopian tube. Following, the Sehane clamp was placed in the mesosalpinx and another curve clamp was placed in the proximal aspect of the left fallopian tube beyond the area of the ectopic pregnancy.
A partial salpingectomy was performed, removing the portion of the left fallopian tube containing the ectopic pregnancy. Any clamps were then replaced with sutures of No. 1 Vicryl. Hemostasis was checked again and no bleeding was detected. Further evacuation of blood and blood clots was then performed. Fallopian tube was noted to be covered with adhesions, both tubo-ovarian and tubo-uterine adhesions. The adhesions were then sharply lysed, freeing the right fallopian tube. Hemostasis was checked again. No bleeding was detected. Mild serosal abrasion was noted from the area where the ectopic pregnancy was apparently attached to the bowel.
This was not bleeding and was very superficial. Hemostasis was checked and no bleeding was detected. The peritoneum was then closed continuously with O-Chromic suture. The fascia was approximated with interrupted figure-of-8 stitches of O-vicryl and the skin was approximated with a staple gun. The patient tolerated the procedure well and left the operating room in satisfactory condition. All counts were correct. Blood loss was estimated at 1000 ml, which was replaced with 2 units of whole blood while in recovery. ______________________ Rosemary Bumbak, MD, OB-GYN PATHOLOGY REPORT.
Patient Name: Brenda C. Seggerman Patient ID: 903321 Date of Surgery: 03/27/2014 Admitting Diagnoses 1. Ectopic Pregnancy PATHOLOGY FINDINGS Specimen No: 03-S-965 Date Specimen Received: 3/27/2014 Date Specimen Reported: 15:30 Surgical Procedure: Left partial salpingectomy CLINICAL HISTORY: The patient has an ectopic pregnancy as proven by pelvic ultrasound. Tissue Received: Left fallopian tube GROSS DESCRIPTION: Exam of the specimen designated “left fallopian tube” reveals the presence of a fallopian tube measuring 6 cm in length and 2. 3 cm in average diameter.
Sectioning of the tube shows it to be distended with blood clot and possible fetal tissue. Representative sections are taken and placed in three cassettes, A through C, for embedding. MICROSCOPIC DESCRIPTION: Microscopic examination performed. MICROSCOPIC DIAGNOSIS: Ruptured tubule pregnancy. ICD Code: 663. 1 _______________________ Berry J. Lozano, MD c: Rosemary BumbakDISCHARGE SUMMARY Patient Name: Brenda C. Seggerman Patient ID: 903321 Date of Admission: 03/27/2014 Date of Discharge: 03/30/2014 Admitting Diagnosis: Ectopic Pregnancy Surgical Procedures: 1. Exploratory laprarotomy 2.
Partial salpingectomy 3. Evacuation of hemoperitoneum 4. Lysis of adhesions Complications: Blood loss requiring transfusion x2. HISTORY: This 35 year-old white female, gravida 3, para 1-0-2-1, had her last menstrual period in early January. Prior menstrual cycles had been regular. She reported using no contraception but not attempting pregnancy. Patient presented to the emergency room complaining of vaginal bleeding with pain in the lower pelvic area. Ultrasound performed in the emergency room showed a 13. 8 cm left adnexal mass with positive cardiac activity compatible with ectopic pregnancy.
HOSPITAL COURSE: On March 27, the patient underwent exploratory laparotomy, left partial salpingectomy, evacuation of hemoperitoneum, and lysis of adhesions. Blood loss was approximately 1000 ml and was replaced with transfusion of two units of red blood cells. Her blood type was noted to be O Rh-negative and RhoGAM was provided. The patient was discharged on post-operative day number 3 after having had a normal bowel movement. She was discharged without complaints on no medications. She understood her instructions regarding follow up, incision care, and limitation of activities. ______________________ Rosemary Bumbak, MD, OB-GYN.