Medical Transcription
HISTORY AND PHYSICAL EXAMINATION
OR EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: Brenda C. Seggerman
Patient ID: 903321
Date of Admission/Data of Arrival: 03/27/2013
Admitting/Attending Physician: Alex Mcclure, MD
Admitting Diagnosis: Ectopic pregnancy.
Chief Complaint: Lower abdominal pain.
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
OR EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: Brenda C. Seggerman
Patient ID: 903321
Date of Admission/Data of Arrival: 03/27/2013
Admitting/Attending Physician: Alex Mcclure, MD
Admitting Diagnosis: Ectopic pregnancy.
Chief Complaint: Lower abdominal pain.
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