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 sexual active and using no birth control. Gynecologic history: patients is gravida 2, para 1, abortus 1, her only child is a 15 year old child who lives in Texas with her grandmother.
PAST HISTORY: positive for hepatitis B. Surgical: pilonidal cyst, removed in the rhoGAM 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 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’s also having some nausea and vomiting. Denies hemotenisis. Hemtacia and melena. She has had vaginal spotting over the
past month, with questionable vaginal discharge as well. Denies uterine frequency, urgency and hematuria. Denies arthralgia. Review all 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 ©2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
Well developed, well-nourished, 35 year old white female. Ad moderate amount of distress. At the time of the examination. HEENT: are unremarkable except for poor dentation. Neoga soft and subtle CHEST: lungs are clear in all fields. HEART: regular rate and rhythm. ABDOMEN: soft with positive tenderness over lower abdominal area. Fundus was not palpable above the pubic area. Left ubnexa are more tender then the right. VAGINAL: the cervix is closed. A mother of the amount of new pepularion 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The patient would not allow me to perform a bimanual examination, due to her pain so the speculum was withdrawn.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 club, no edema. NEUROLOGIC: intact are young x3 no neurologic deficits. DIAGNOSTIC DATA: admission hemoglobin 12. 8g. Hematocrit 36. 6%, urinalysis is essentially negative, Beta-hCG positive with a WBC 23000/178 radiology pelvic ultrasound shows a 7 week 4 day old viable ectopic pregnancy per radiology. ASSESSMENT: The patient was given Demerol 25 mg and Phenergan 25 mg IV for the pain after her report was updated.
She was also given Claforan 1g 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 personal advised me he is not at home. Doctor Bonbeck is on call. I spoke with Doctor Bonbeck at approximately 10:25 a. m. and she will be her to take the patient to the operating room. Admitting diagnosis: left ectopic first trimester pregnancy. This position the patient received an IV of lactated ringer’s upon arrival at the emergency room.
This was switched to normal saline why we were waiting for Bonbeck’s arrival. The surgical procedure was explained to the patient and her husband all the risk and the benefits were discussed. They understand the necessity for immediate surgery and inform consent was signed. No old records are available for review. _______________ Alex Mcclure, MD AM: xx D: 3/27/2014 T: 3/27/2014 ©2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.