HISTORY AND PHYSICAL EXAM or EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: Brenda C. Seggermen
Patient ID: 903321
Time of Admission/Date of Entrance: 3/27/----
Admitting/Attending Physician: Alex McClure, MD
Admitting Diagnosis: Ectopic pregnancy
CHIEF PROBLEM: The patient was admitting towards the emergency room this morning complaining of abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient states that she has recently been having vaginal bleeding more like spotting over the past month. She forbids the chance of pregnancy, although she says that she has been sexual active and using not any birth control.
GYNECOLOGY HISTORY: Affected person is gravida 2, afin de, 1, abortus 1 her only kid is a 15-year-old daughter that lives in Texas with her grandmother.
PAST CLINICAL: Positive intended for hepatitis W.
PAST SURGICAL HISTORY: Pilonidal cyst taken off in the remote past. Acquired plastic surgery onto her ears provides a child.
SOCIABLE HISTORY: Married has a single daughter; individual works contains a substitute tutor. Smokes a single pack of cigarette every day. Denies EtOH. Smoke cannabis last night. Not any IV substance abuse. (Continued
EMERGENCY PROVIDERS ADMISSION RECORD
Patient Identity: Brenda C. Seggermen
Affected person ID: 903321
Date of Admission: 3/27/----
Page a couple of
REVIEW PROGRAM: Patient gripes of lower abdominal soreness for the past week that evidently got much worse last night and by today wasn't not bearable she also having some nausea and nausea. Denied hematemesis, hematochezia and melena. This wounderful woman has had penile spotting over past month with questionable genital discharge as well.
Rejected urinal consistency urgency and hematuria. Refused. Review of method is otherwise essentially negative.
PHYSICAL EXAMINATION: Vital signs shows temperature for 97 level, pulse 53, respiration twenty-two, blood pressure 108/60 GENERAL: physical exam discloses a well-develop, well-nourish thirty-five year...