Physical Examination Case Study

 

Patient's Name:

Jeneth Sulayman

Religion:

Roman Catholic

Age/Gender:

28 years old

Room/Bed #:

Main Station FW3

Physical AssessmentGeneral Survey:

Vital signs are: body temperature of 35.7 C; pulse rate 82 beats per minute withregular rhythm upon palpatation; respiratory rate of 27 cycles per minute with regular rhytm; with equal expansion of the chest; blood pressure of systolic 130 and diastolic of 90 mmHg noted upon auscultation.Patient is awake , conscious and coherent. Speech is adequate and conversesare well oriented. Client is responsive to questions both verbally and physically.

Skin:

Patient has brown skin complexion upon inspection. Hypertrophic scar secondary to caesarian section approximately 4.5 inches long noted on the lower abdomen. Stretch marks noted, white in color and approximately 3 to 4 incheslong noted. Discoloration of the lateral grooves of the thumb nails noted. Skin onthe right arm is punctured due to intravenous fluid infusion but with no notedswelling, reddening, heat and pain. Body hair is fine and thinly distributed. Skin iswarm to touch, with good skin turgor, and with adequate moisture upon palpation.

Head:

Head is symmetrical upon inspection. Long, fine, black, wavy hair noted in thindistribution. Nodular lesions with brown color and equally distributed noted on the faceupon inspection. No masses noted upon palpatation. The client doesn’t complain of dizziness, vertigo and headache upon the interview. She has no family history of mentaldisorders noted upon assessment of her/his family background.

E

ARS

:

HISTORY OF PRESENT ILLNESS: The patient states that she has been having some vaginal bleeding, more like spotting over the past month. She denies the chance of pregnancy although she states that she is sexually active and using no birth control.

GYNOCOLOGIC HISTORY: Patient is gravida 2, para 1, abortus 1 the only child is a 15 year old daughter who lives in Texas with her grandmother.

PAST MEDICAL HISTORY: Positive for Hepatitis B.

PAST SURGICAL HISTORY: Pilonidal cyst removed in the remote past; had plastic surgery on her ears as a 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: None.

TETANUS: None.

MEDICATIONS: None.

REVIEW OF SYSTEMS: Patient complains of a lower abdominal pain for the past week that apparently got much worse last night and by this morning was intolerable. She is also having some nausea and vomiting. Denies hematemesis emodocesia and melena. She has had vaginal spotting over the past month with questionable vaginal discharge as well. Denies urinary frequency urgency and hematuria. Denies arthralgias. Review of systems is otherwise essentially negative.

PHYSICAL EXAMINATION: Vital signs show temperature at 97 degrees. Pulse 53. Respirations 22. Blood pressure 108/60.

HISTORY AND PHYSICAL EXAMINATION OR EMERGENCY DEPARTMENT TREATMENT RECORD

Patient Name: Brenda C. Seggerman

Patient ID: 903321 Date of Admission 12/01/2014 Page 2

GENERAL: Physical exam reveals a well-developed well-nourished 35 year old white female in a moderate amount of distress at the time of the examination.

HEENT: are unremarkable except for poor dentation.

NECK: Soft and supple.

CHEST: Lungs have cleared in all fields.

HEART: Regular rate and rhythm.

ABDOMEN: Soft with positive tenderness of the lower abdominal area. Fondest was not palpable above the pubic area. Left adnexa are more tender than the right.

VAGINAL EXAM: The cervix is closed. A moderate amount of mucopurulent vaginal discharge is noted. The patient would not allow me to perform a bimanual examination due to her pain, so the speculum was withdrawn.

EXTRMETIES: No clot, or edema.

NEUROLOGIC EXAM: Intact are yenta times 3, no neurologic deficits.

DAGNOSTIC DATA: Admission hemoglobin 12. 8 grams, hematocrit 36. 6%. Urinalysis is essentially negative. Beta-hCG is positive with a WBC count of 23,278

RADIOLOGY: Pelvic ultrasound shows a 7 week 4 day old viable ectopic pregnancy per radiology. The patient was given Demerol 25 milligrams and Phenergan 25 milligrams IV for the pain after her report was obtained. She was also given Claforan 1 gram IV. I paged Dr. Gerard, patients GYN physician as soon as I received the ultrasound report at approximately 10:00 a. m. He was not in his North Miami office. I paged the South Miami office and reached Dr. Gerard’s office at approximately 10:15 a. m. His office personnel advised me that he is not on call. Dr. Bonbeck is on call. I spoke with Dr. Bonbeck at approximately 10:25 a. m. and she will be here to take the patient to the operating room.

ADMITTING DIAGNOSIS: Left ectopic first trimester pregnancy.

DISPOSITION: The patient received an IV of lactated ringers upon arrival at the emergency room. This was switched to normal saline while we were awaiting Dr. Bonbeck’s arrival. The surgical procedure was explained to the patient and her husband. All this risks and benefits were discussed. They understand the necessity for immediate surgery and an informed consent was signed. No old records are available for review.

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