HISTORY OF PRESENT ILLNESS: The patient states 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.
GYNECOLOGY 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 one 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 a lower abdominal pain for the past week that apparently got much worst last night and by this morning was intolerable. She is also having some nausea and vomiting. Denies hematemesis, hematokesa, and melena. She has had vaginal spotting over the past month with questionable vaginal discharge as well. Denies
(continued)
EMERGENCY SERVICES ADMISSION REPORT
Patient Name: Brenda C. Seggerman
Patient ID: 903321
Date of Admission/Data of Arrival: 03/27/2013
Page 2
urinary frequency, urgency, and hematuria. Denies arthralgia. The view of systems is otherwise essentially negatives.
PHYSICAL EXAMINATION: VITAL SIGNS: Show temperature 97 degrees, pulse 53, respirations 22, and 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. HEENT: Are all 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 lower abdominal area. Fungus was not palpable above the pubic area. Left adnexa are more tender than the right. VAGINAL EXAM: The cervix is close. 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 The patient would not allow me to perform a bimanual examination due to her pain so the speculum was withdrawn.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. NEUROLOGICAL EXAM: Intact. Oriented X3. No neurologic deficits.
DIAGNOSTIC DATA: Admission hemoglobin 12.8g, hematocrit 36.6%, URINALYSIS: is essentially negative. BETA HCG: Is positive with a WBC Count of 23,278.
RADIOLOGY: Pelvic ultrasound should a 7 week 4 day viable ectopic pregnancy per radiology. The patient was given demerol 25mg and phenergan 25mg. IV for the pain after her report was obtain. She was also given claforan 1g IV. I page Dr. Gerard, Patient’s GYN physician as soon as I had received the ultrasound report at approximately 10am.
He was not in his north Miami office. I page the south Miami office and reached Dr. Gerard’s office at approximately 10:15 a.m. His office personnel advise me that he is not on call. Dr. Bomback is on call. I spoke with Dr. Bomback at approximately at 10:25 a.m. and she will be here to take the patient to the operating room.
(continued)
EMERGENCY SERVICES ADMISSION REPORT
Patient Name: Brenda C. Seggerman
Patient ID: 903321
Date of Admission/Data of Arrival: 03/27/2013
Page 3
ADMITTING DIAGNOSIS: Left ectopic first trimester pregnancy. Disposition. The patient receives an IV of lactated ringer’s upon arrival at the emergency room. This was switch to normal saline while we were awaiting Dr. Bomback’s arrival. The surgical procedure was explained to the patient and her husband. All the risk 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
AM:TB
D:03/27/2013
T:01/09/2013