Vital Signs
CASE STUDY 1
EMERGENCY SERVICES ADMISSION REPORT
Patient ID: 903321
Date of Admission: 03/27/2013
Emergency Room Physician: Alex McClure, MD
Admitting Diagnosis: Ectopic pregnancy.
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 sexually active and using no birth control.
GYNECOLOGIC 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, 1 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, but 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 arthralgia. Review of systems is otherwise essentially negative.
PHYSICAL EXAMINATION: 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. VITAL SIGNS: Show temperature 97 degrees; pulse 53; respirations 22; blood pressure 108/60. HEENT: Unremarkable except for poor dentation. Neck: Soft and supple. CHEST: Lungs are clear in all ???. HEART: Regular rate and rhythm. ABDOMEN: Soft but positive tenderness of her lower abdominal
EMERGENCY SERVICES ADMISSION REPORT
Patient ID: 903321
Date of Admission: 03/27/2013
Emergency Room Physician: Alex McClure, MD
Admitting Diagnosis: Ectopic pregnancy.
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 sexually active and using no birth control.
GYNECOLOGIC 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, 1 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, but 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 arthralgia. Review of systems is otherwise essentially negative.
PHYSICAL EXAMINATION: 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. VITAL SIGNS: Show temperature 97 degrees; pulse 53; respirations 22; blood pressure 108/60. HEENT: Unremarkable except for poor dentation. Neck: Soft and supple. CHEST: Lungs are clear in all ???. HEART: Regular rate and rhythm. ABDOMEN: Soft but positive tenderness of her lower abdominal