Admitting diagnosis: Egtopic pregnancy Essay

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: Regular rate and rhythm. ABDOMEN: soft but positive  tenderness of her lower abdominal area. Fundus was not palpable. above the pubic area. Left andexal are more than tender than the right. VAGINAL: The cervix is closed. a moderate amount of motherapulient vaginal discharge is noted. the patient wouldn’t allow me to perform a bimanual examination due to her pain. so the speculum was withdrawn. EXTERMITIES: No clot or edema. NUEROLOGICAL-in tact urea x3, no nuerologica defictest. DIAGNOSTIC: Dr. on admission hemoglobin 12.8 grams, hemaocrit is 36.6%. urine analysis is essentially negative. beta hcg is positive wit the WBC count of 23,278 RADIOLOGY: Pelvic ultrasounds shows a 7 week 4 day off viable ectopic pregnancy per radiologist. the patient was given Demerol 25mg and Phenergan 25mg iv for the pain after her report was obtained. she was also given Claforan 1 gram iv, I paged Dr. Gerald GYN, physician as soon as they received the ultrasound report at approximately 10 am he was not in his north Miami office. I paged the south Miami office and reached Dr. Gerards office at approximately 10:15am. his office personnel advised me that he is not on call, Dr. Vonbeck is on call. I spoke with Dr. Vonbeck at approximately 10:25 am and she will be here to take the patient to the operating room. ADMITTING DIAGNOSIS: Left Ectopic 1st trimester pregnancy. The patient received and iv of lactated ringer’s upon the arrival in the emergency room. This was normal saline while we were awaiting Dr. Vonbecks arrival. The surgical procedure was explained the patient and her husband all the risk and benefits were discussed. Then assessing in immediate surgery and informed consent was signed. no old records are available for review. Dr McClure end dictation. Rosemary Bumbak dictating a OPERATIVE REPORT Patient Name: Brenda C. Seggerman Patient ID: 903321 Date of Admission: 03/27/2012 Date of Surgery: 03/27/2012 Surgeon: Rosemary Bumbak, MD Assistant: Michael Gerard , DO Anesthesiologist: General and tracheal by Dr. Avalon Estimated Blood Loss: approximately 1000ml required transfusion of 2 units of whole blood. specimen removed portion of left fallopian tube containing the ectopic pregnancy. Preoperative Diagnosis: left tubectoipc pregnancy Postoperative Diagnosis: 1 rupture let tubal ectopic pregnancy 2. Hemoperiteoneum 3-pelvic adhesions Surgical Procedures: 1-exploratory laperotomy 2-partial salpingectomy 3-evauation of hempopatium 4-lisis of adhesions Procedure in detail: The patient was prepped and draped in the usual manner and placed under adequate general anesthesia, Pfannenstiel incision was preformed and carried through skin and subcutanous tissue, fascia and peritoneum. the paritenial cavity was entered. the hemoparituim was noted, and approximately 500 ml of blood was rapid evacuated from the pelvic cavity, as were large cloths, following this, the bowel was packed away the pelvic area with packing lapse. A retaining retractor was introduced. The left fallopian tube was noted. A large tubalectopic pregnancy was noted effecting approximately the distal half of the fallopian tube. Following this Heaney clamp was placed and the mesosalpinx cell and another curver clamp was paced in the proximal aspect of the left fallopian tube beyond the area of ectopic pregnancy. A patial salpiingectomy was preformed. removing the portion of the left fallopian tube containing the ectopic pregnancy. Heaney clamps were replaced with sutures with #1 micro. Hemostasis was checked again and no bleeding was detected. Further evacuation of blood and blood clots was then preformed. the right fallopian tube was noted to be covered with adhesions both tubular variatand tubal uterine The adhesions were then sharply lysed freeing the right fallopian tube. Hemostasis was checked again. No bleeding was detected. Mild cirrhosis abrasion was noted was noted where the area of the ectopic pregnancy was apparently attached to the bowel and not bleeding and was very superficial. hemostasis was checked and no bleeding was detected. The peritoneum was closed continuously was homeochinoc suture. The facsia was approximated was inntrupted with  figure of 8 stitches of micro and the skin was approximated with staple gun. The patient tolerated the procedure well and left the operating room in satisfactory condition. All counts were correct. Blood loss was estimated at 1000ml which was replaced with 2 untis of whole blood while in recovery. Rosemary Bumpbak, MD OBGYN DIAGNOSTIC REPORT Dr Donna Harrison dictation Patient Name: Brenda C. Seggerman Patient ID: 903321 Date of Admission: 3-27-2012 ER Physician: Alex McClure MD Transvaginal ultrasound on 3-27-14 Patient History: Serve left pelvic pain rule out ectopic pregnancy. Pregnancy test is positive. Findings-transabdominal imaging demonstrates utures with small amount of fluid within it Psudodecidual sign. There is a large amount of hemorrhage seen within the left adnexa. no embryo is seen. The right ovary is unremarkable Endovaginal examination was performed in searched of viable ectopic. One is seen with crown length with 1.3cm corresponding to 7 weeks and 4 days. A large amount of free fluid is seen, esooudo gestuational sac is noted within the uterus which is oblong. IMPRESSION: A left sided ectopic pregnancy is found with large amount of hemorrhage is noted and extending into the cul-de-sac the hemorrhage measures 13x6x10cm. Dr. McClur and the emergency room was notified which notified the surgeon and is on her way, end of report Dr Harrison. (Contiuned) _________________________ Dr. Donna Harrison NN:EF D: 3/27/2012 T: 3/27/2012 Please send a copy of this report to Rosemary Bumbak, MD OBGYN DISCHARGE SUMMARY Rosemary Bumbak, MD OBGYN Patient Name : Brenda C. Seggerman Patient ID: 903321 Date of Admission: 03/27/2012 Date of Discharge: 03/30/2012 Admitting Diagnosis: ectopic pregnancy Surgical procedures: 1-expoloratory laparotomy 2-partioal salpingectomy 3-evacation of hemoparitoneum 4-lises of adhesions Complication-blood loss requiring transfusion x2 History: This 35 year old white female Gravida 3 para 10121 had her last menstrual cycle in early January. Prior menstrual cycles had been regular. She reported no contraceptives but not attempting pregnancy. Patient presented to the emergency room complaining of vaginal bleeding with pain in lower pelvic area. ultrasound preformed in the emergency room showed a 13.8 cm left adnexall mass with positive cardiac activity compatible with ectopic pregnancy. Hospital Course: On 3-27-2014 the patient underwent exploratory laparotomy, left partial salpingectomy, evacuation of hemoparitoneum, and lyses of adhesions. Blood loss was approx 1000ml and was replaced with transfusion of 2 units of red blood cells the blood type was noted to be ORH negative and RhoGAM was provided. The patient was discharged on post operative on day number 3 on after having a normal bowel movement she was discharged with complaints on no medications. She understood her instructions regarding follow up, wound care a nd limitations Rosemary Bumbak ,MD OBGYN PATHOLOGY REPORT Berry J Lzano, dictation for PATIENT NAME: Brenda C. Seggerman. PATIENT ID: 903321 Date of Admission: 3/27/2012 Surgery: 3-27-2014 Admitting diagnosis: Ectopic pregnancy Surgeon: Rosemary Bumback, MD OBGYN Pathological Findings: 03-s-965 specimen received 3/27 specimen report 3-320 Procedure: left partial salpingectomy The patient has a ectopic pregnancy as proven by pelvic ultrasound. tissue received left fallopian tube. GROSS PATHOLOGY: desc examination of designated â€Å"left fallopian tube† reveals a left fallopian tube measuring 6cm in length and 2.3 cm in normal width. Sectioning of the tube reveals a distending of the tube with blood clot and possible field tissue. reprehensive sections are places in 1-c for embedding MICROSCOPIC: Microscopic examination was preformed