Case 1 Reproductive System
HISTORY AND PHYSICAL EXAMINATION
OR EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: Brenda C. Seggerman
Patient ID: 903321
Date of Admission/Date of Arrival: 03/27/2014
Admitting/Attending Physician: Alex McClure, MD
Admitting Diagnosis: Ectopic Pregnancy
Chief Complaint: 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, para 1, abortus 1. He only child is a 15 year old daughter who lives in Texas with her grandmother.
PAST HISTORY: Positive for Hepatitis B.
SURGICAL HISTORY: Pilonidal cyst removed in the emote 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: Ketenes
MEDICATIONS: None.
REVIEW OF SYSTEMS: Patient complains of a 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: temperature 97.0, pulse 53, respirations 22, blood pressure 108/60. General.
(Continued)
HISTORY AND PHYSICAL EXAMINATION
OR EMERGENCY DEPARTMENT TREATMENT RECORD
Patient name: Brenda C. Saggerman
Patient ID:
Date of Admission:
Page 2
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.
OR EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: Brenda C. Seggerman
Patient ID: 903321
Date of Admission/Date of Arrival: 03/27/2014
Admitting/Attending Physician: Alex McClure, MD
Admitting Diagnosis: Ectopic Pregnancy
Chief Complaint: 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, para 1, abortus 1. He only child is a 15 year old daughter who lives in Texas with her grandmother.
PAST HISTORY: Positive for Hepatitis B.
SURGICAL HISTORY: Pilonidal cyst removed in the emote 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: Ketenes
MEDICATIONS: None.
REVIEW OF SYSTEMS: Patient complains of a 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: temperature 97.0, pulse 53, respirations 22, blood pressure 108/60. General.
(Continued)
HISTORY AND PHYSICAL EXAMINATION
OR EMERGENCY DEPARTMENT TREATMENT RECORD
Patient name: Brenda C. Saggerman
Patient ID:
Date of Admission:
Page 2
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.