Essay on Brenda Seggerman HP - 612 Words

EMERGENCY DEPARTMENT TREATMENT RECORD Patient Name: Brenda C. Seegerman Patient ID:903321 Date of Admission 3/27/2012 Emergency Room Physician: Alex McClure, MD Admitting Diagnosis: Eptopic 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 stated that she is sexually active and using no birth control. GYNECOLOGIC HISTORY: Patient is gravid 2, para 1, abortus 1. Her only child is a 15-year-old daughter who lives in Texas with her grandmother. PAST MEDICAL HISTORY:†¦show more content†¦Heart: Regular rate and rhythm. Abdomen: Soft with positive tenderness of her lowed abdominal area.Fundus was not palpable above the pubic area. Left adnexa are more tender than the right. Viginal exam: The cervix is closed. A moderate amount of mucopuruent vaginal discharge is noted. The patient would not allow me to perform a bimanual examination due to her pain, so the speculum was withdrawn. Extremities: No clot, no edema. Neurologic exam: Intact, oriented x3. No neurologic deficits. DIAGNOSTIC DATA: Admissions hemoglobin 12.8g, hematocrit 36.6%. Urinalysis is essentially negative. Beta-hCG is positive with a WBC count of 23,278. RADIOLOGY: Pelvic ultrasound shows a 7week 4-day-old viable ectopic pregnancy pre Radiology. The patient was given Demerol 25mg and Phenergan 25 mg IV for the pain after her report was obtained. She was also given Claforan 1 g IV. I paged Dr. Gerard, patient’s GYN physicial, as soon as I recived the ultrasound report at approximately 10 a.m. His office personnel advised me that he is not on call. Dr. Bumbak is on call. I spoke with Dr. Bumbak at approximately 10:25 a.m., and she will be here to take the patient to the operating room. ADMITING DIAGNOSIS: Left ectopic first-trimester pregency. DISPOSITION: The patient received an IV of lactated Ringer’s upon arrival at the emergency room. This was switched to normal saline while we were awaiting Dr. Bumbak’s arrival. The surgical procedure was explained to the patient and her