HISTORY AND PHYSICAL EXAM (H& P)
Patient Name: Brenda Seggerman
Hospital Number: N/A
Space No .: N/A
Date of Admission: 03/27/- - -- -
Acknowledging Physician: Alex Mcclure, MD
Admitting Prognosis: Ectopic Pregnancy
HISTORY OF PRESENT ILLNESS: The patient declares that this lady has been having vaginal bleeding similar to spotting within the last month. The individual denies the possibility of motherhood, although the affected person states that she is sexually active and using not any birth control.
GYNECOLOGICAL HISTORY: Affected person is gravada 2, pra 1, abortus 1 . The patient's only child can be described as 15 year old daughter who also lives in Texas with her grandmother.
PAST MEDICAL HISTORY: Affected person had a Pilonidal cyst taken out. Had cosmetic plastic surgery on her ear canal as a child.
SOCIAL HISTORY: Patient is usually married and has you daughter. The lady works as a replace teacher. Smoking cigarettes 1 pack of cigarettes on a daily basis. Denies EtOH. Smoked weed last night. No IV drug abuse.
MEDICATIONS: None of them.
REPORT ON SYSTEMS: Patient complains of her reduce abdominal pain the past week that obviously got very much worse yesterday evening by this morning hours was inaguantable. She is also having some nausea and vomiting. Denies hematemesis, hematochezia, and melena. She has had vaginal distinguishing over the past month with suspect vaginal release as well. Refuses urinary rate of recurrence, urgency, and hematuria. Individual also forbids arthralgias.
REPORT ON SYSTEMS: Normally essentially bad.
PHYSICAL EVALUATION: Vital symptoms temperature ninety-seven degrees, heartbeat 53, respirations 22, stress 108/60.
BASIC: Physical test reveals a well-developed, well-nourished 35 year-old white female in a HISTORY AND PHYSICAL EXAM (H& P)
Patient Brand: Brenda Seggerman
Patient IDENTIFICATION: 903321
Day of Entrance: 03/27/- -- - --