Hillcrest Medical Case 1
HISTORY AND PHYSICAL EXAMINATION
Good morning this is Alex McClure, MD dictating
PATIENT NAME: Brenda c. Seggerman
PATIENT ID: 903321
Date of Admission: 3/27/2012
EMERGENCY ROOM Physical: Alex McClure. MD
Admitting diagnosis: Egtopic pregnancy
Chief Complain: The patient presents in the emergency 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 she is sexually active and using no birth control.
Gynecologic History: Patient is graved to par 1 abortus 1. her only child is a year old 15 year old daughter who lives in Texas that lives with her grandmother.
PAST MEDICAL HISTORY: Positive for hepatitis B
PAST SURGICAL HISTORY: Pilonidal cyst removed in the remote past, has plastic surgery on her ears child.
SOCIAL HISTORY: Married, has 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
MEDICATION: None
REVIEW OF SYSTEMS: Patient complains of lower abdominal pain for the past week. Apparently got much worse last night, and by this morning wasn’t tolerable. She is also having some nausea and vomiting, denies hematemesis and mel?? She has had vaginal spotting over the past month with questionable vaginal discharge as well. denies the frequency, urgency and hematuria and denies arthralgia. Review of systems is otherwise essentially negative.
PHYSICAL EXAM: Vital signs show temperature 97 degrees. pulse 53 respirations 22. blood pressure 108/60. GENERAL: Physical exam revels a well developed, well nourished 35 year old white female is the moderate amount of distress the time of the examination, HEENT are all remarkable except poor indentation. neck is soft and supple. CHEST: Lungs are clear in both fields. HEART:
Good morning this is Alex McClure, MD dictating
PATIENT NAME: Brenda c. Seggerman
PATIENT ID: 903321
Date of Admission: 3/27/2012
EMERGENCY ROOM Physical: Alex McClure. MD
Admitting diagnosis: Egtopic pregnancy
Chief Complain: The patient presents in the emergency 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 she is sexually active and using no birth control.
Gynecologic History: Patient is graved to par 1 abortus 1. her only child is a year old 15 year old daughter who lives in Texas that lives with her grandmother.
PAST MEDICAL HISTORY: Positive for hepatitis B
PAST SURGICAL HISTORY: Pilonidal cyst removed in the remote past, has plastic surgery on her ears child.
SOCIAL HISTORY: Married, has 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
MEDICATION: None
REVIEW OF SYSTEMS: Patient complains of lower abdominal pain for the past week. Apparently got much worse last night, and by this morning wasn’t tolerable. She is also having some nausea and vomiting, denies hematemesis and mel?? She has had vaginal spotting over the past month with questionable vaginal discharge as well. denies the frequency, urgency and hematuria and denies arthralgia. Review of systems is otherwise essentially negative.
PHYSICAL EXAM: Vital signs show temperature 97 degrees. pulse 53 respirations 22. blood pressure 108/60. GENERAL: Physical exam revels a well developed, well nourished 35 year old white female is the moderate amount of distress the time of the examination, HEENT are all remarkable except poor indentation. neck is soft and supple. CHEST: Lungs are clear in both fields. HEART: