Example 1 Background Physical Evaluation

 Case Study one particular History and Physical Examination Dissertation

п»їHISTORY AND PHYSICAL EXAMIATION

OR PERHAPS EMERGENCY OFFICE TREATMENT RECORD

Patient Brand: Brenda C. Seggerman

Affected person ID: 903321

Room No .:

Date of Admission/ Particular date of Arrival: 3/27

Admitting/ Attending Doctor: Alex McClure, MD

Acknowledging Diagnosis: Ectopic Pregnancy

Chief Complaint: Reduce Abdominal Soreness

HISTORY OF PRESENT ILLNESS: The patient states that she has been having some vaginal bleeding, a lot more like spotting within the last month. The girl denies the opportunity of pregnant state although your woman states that she is sexually active and using no birth control. GYNOCOLOGIC HISTORY: Individual is gravida 2, em virtude de 1, abortus 1 the sole child can be described as 15 year old daughter who also lives in The state of texas with her grandmother. EARLIER MEDICAL HISTORY: Positive for Hepatitis B.

PREVIOUS SURGICAL BACKGROUND: Pilonidal cyst removed in the remote past; had cosmetic surgery on her ears as a child. SOCIABLE HISTORY: Hitched, has one particular daughter. Individual works as a replacement teacher. Cigarettes 1 pack of cigarettes every day. Denies ETOH. Smoked marijuana last night. Simply no IV drug abuse. ALLERGIES: Not one.

TETANUS: Probably none.

MEDICATIONS: None of them.

REVIEW OF DEVICES: Patient gripes of a lower abdominal pain for the past week that apparently got much worse yesterday evening and by today was irresistible. She is also having a lot of nausea and vomiting. Refuses hematemesis emodocesia and melena. She has got vaginal recognizing over the past month with questionable vaginal discharge as well. Forbids urinary regularity urgency and hematuria. Forbids arthralgias. Review of systems is definitely otherwise essentially negative. PHYSICAL EXAMINATION: Vital signs display temperature for 97 levels. Pulse 53. Respirations twenty-two. Blood pressure 108/60.

HISTORY AND PHYSICAL ASSESSMENT

OR CRISIS DEPARTMENT TREATMENT RECORD

Patient Name: Brenda C. Seggerman

Patient IDENTITY: 903321

Day of Entrance 12/01/2014

Webpage 2

STANDARD: Physical examination reveals a well-developed well-nourished 35 yr old white female in a modest amount of distress during the time of...


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