Chief Complaint: The patient presents in 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.
Gynecologic History: Patient is gravida 2, para1, 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: Pilodinal 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 Marihuana last night. No IV drug abuse.
Allergies: TETANUS
Medication: None
HISTORY AND PHYSICAL EXAMINATION
OR EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: Brenda C. Seggerman
Patient ID: 903321
Date of Admission: 3/27/—-
Page 2
Review Systems: Patients complains of a lower abdominal pain for the past week that apparently got much worse last night and by this morning wasn’t tolerable. 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 Arthralgia. Review of systems is otherwise essentially negative.
Physical Examination: Vital signs show T 97 degrees, P 53, R 22, BP 108/60.
General Physical Exam reveals a well developed, well nourishes 35 year-old white female in a moderate amount of distress at the time of the examination. Heent are remarkable except for poor dentition.
Neck: Soft and supple
Chest: Lungs are clear in all fields
Heart: Regular rate and rhythm
Abdomen: Soft with positive tenderness of the lower abdominal area. From this was not palpable above the pubic area. Left adnexa are more tend than the right.
Vaginal Exam: The cervix is close. A moderate amount of mucopurulentvaginal discharge is noted. The patient will not allow me to perform a vaginal examination due to her pain, so the speculum was withdrawn.
Extremities: no clot. No edema.
Neurological Exam: Intact, orientedx3. No neurologic deficits.
HISTORY AND PHYSICAL EXAMINATION
OR EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: Brenda C. Seggerman
Patient ID: 903321
Date of Admission: 3/27/—-
Page 3
Diagnostic Doctor: Admission Hemoglobin 12.8g, Hematocrit 36.6% Urinalysis is essentially negative. ACG 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 25mgs and Phenergan 25mgs. IV for the pain after her report was updated. She was also given Claforan 1g IV. I paged Dr. Gerard, patient’s GYN physician as soon as they received the ultrasound report at approximately 10:00 a.m. He was not in his North Miami office.
I paged the South Miami office and reached and Dr. Gerard 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 at 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 or Lactated Ringer’s upon arrival at the emergency room. This was switch to normal saline while we were awaiting for Dr. Bumbak. 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 more records are available for review.
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Alex McClure, MD
03/27/—