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 subtle.
CHEST: lungs are clear in all fields. HEART: regular rate and rythem. 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. VAGINAL 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 The patient would not allow me to perform a bimanual examination due to her pain so the speculum was withdrawn. EXTREMITIES: no clot, no edema. NEUROLOGIC: intact oriented x3. No neurologic defects.
DIAGNOSTIC DATA: Admission hemoglobin12.8g, hematocrit 36.9%, urinalysis is essentially negative, beta-hCG is positive with a WBC count 23,278.
RADIOLOGY: Pelvic ultrasound shows a 7 week 4 day old viable ectopic pregnancy per radiology. The patient was given Demerol 25mg and Phenergan 25mg IV for the pain after her report was obtained. She was also given Claforan 1g IV. I paged Dr. Gerard, patient’s gynecology physician as soon as I received the ultrasound report at approximately 10 am. He was not in his North Miami office. I paged the South Miami Office and reached Dr. Gerard’s office at approximately 10:15 am. His office personnel advised me he is not on call. Dr. Bumbak is on call. I spoke with Dr. Bumbak at approximately 10:25 am and she will be here to take the patient to the operating room.
(Continued)
HISTORY AND PHYSICAL EXAMINATION
Patient Name: Brenda C Seggerman
Patient ID: 903321
Date of Admission: 03/27/—-
Page 2
DISPOSTION: 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 the 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 Emergency Department Physician
AM:ST
D:03/27/—-
T:03/27/—-