CHIEF COMPLAINT: The patient was admitting to the emergency room this morning complaining of 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’s been sexual active and using no birth control.
GYNECOLOGY HISTORY: Patient is gravida 2, para, 1, abortus 1 her only child is a 15-year-old daughter that lives in Texas with her grandmother.
PAST CLINICAL: Positive for hepatitis B.
PAST SURGICAL HISTORY: Pilonidal cyst removed in the remote past. Had plastic surgery on her ears has a child.
SOCIAL HISTORY: Married has one daughter; patient works has a substitute teacher. Smokes one pack of cigarette on a daily basis. Denies EtOH. Smoke marijuana last night. No IV drug abuse. (Continued
ALLERGIES: TETANUS.
Medication: None.
(Continued)
EMERGENCY SERVICES ADMISSION REPORT
Patient Name: Brenda C. Seggermen
Patient ID: 903321
Date of Admission: 3/27/—-
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REVIEW SYSTEM: Patient complains of lower abdominal pain for the past week that apparently got much worse last night and by this morning wasn’t unbearable she also having some nausea and vomiting. Denied hematemesis, hematochezia and melena. She has had vaginal spotting over past month with questionable vaginal discharge as well.
Denied urinal frequency urgency and hematuria. Denied. Review of system is otherwise essentially negative.
PHYSICAL EXAMINATION: Vital signs shows temperature at 97 degree, pulse 53, respiration 22, blood pressure 108/60 GENERAL: physical exam reveals a well-develop, well-nourish 35 year old white female in a moderate amount of distress at the time of the examination. HEENT: are 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 the lower abdominal area. Fundus was not palpable above the pubic area.
Left adnexa are tenderer than the right. VAGINAL DISCHARGE: The cervix is close. A moderate amount of mucopurulent vaginal discharge is noted the patient did not allow me to perform bimanual examination due to her pain so the speculum was withdrawn. EXTREMITIES: no clot no edema neurologic exam: intact orientatx3 no neurologic deficit.
DIAGNOSTIC DATA: admission hemoglobin 12.8 brands, hematocrit 36.6 percent, and urinalysis are sensually negative. Bata-hCG is positive with WBC count of 23,278.
RADIOLOGY: pelvic ultrasound shows 7 week 4 days old viable Ectopic pregnancy per radiologist
(Continued)
EMERGENCY SERVICES ADMISSION REPORT
Patient Name: Brenda C. Seggermen
Patient ID: 903321
Date of Admission: 3/27/—-
Page 3
The patient was given Demerol 25 mg and Phenergan 25 mg IV for her pain after her report was obtained. She was also given Claforam 1 gram IV. I paged Dr. Gerard patient GYN physician as soon as I received the ultrasound report at approximately 10:00 a.m. he was not in his North Miami office. I page the south office Miami office and reach Dr. Garrard office at approximately 10:15 a.m. his office personal advised me that he’s not on call. Dr. Bumbak is on call. I spoke to 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 receives IV of lactated Ringer’s upon arrival at the emergency room. This was switch to normal sailing while we were awaiting Dr. Bombrack arrival the surgical procedure was explain to the patient and her husband all risk and benefit were discuses. Then standard necessity to immediate surgery and inform consent was signed. Now all record is available for review.
____________________________
Alex McClure, MD
Emergency Department Physician
AM: xx
D: 03/27/—-
T: 03/27/—-