ob 15

BMT GRAY – OB-GYN #15
LOD = 1:59

HISTORY AND PHYSICAL EXAMINATION

DIAGNOSIS: Incomplete abortion.

SUMMARY: This patient is a 16-year-old G1P0 gravida 1, para 0, menarche at aged age 13, whose last menstrual period was March 11 to have a , who had a [minus 1.5 for INCORRECT ENGLISH WORD/s] positive beta HCGhCG; [minus 0.5 for CAPITALIZATION ERROR] previous to that, normal menstrual cyclecycles every 28 days. She saidsays [minus 0.5 for WRONG TENSE OF VERB] that she has never had a Pap smear. She was originally seen 2 days ago regarding vaginal bleeding and thought that she had passpassed [minus 0.5 for WRONG TENSE] some tissue. She felt that she probably had spontaneously abortiveaborted [minus 1.5 for INCORRECT ENGLISH WORD] completely. She was told to come to the office in the event of any increaseincreased [minus 0.5 for GRAMMAR ERROR] vaginal bleeding. The bleeding temporized yesterday, but it then became heavy today with a lot of uterine cramps and passing of large clots since and [minus 0.5 for WRONG CONJUNCTION / PREPOSITION / ARTICLE] some further tissue -like material in herper vagina. She did not save any of this material for cross us [minus 1.5 for INCORRECT ENGLISH WORD] for examination.

At the time of the office visit today, she was bleeding more than would be usual for her period, with crampy abdominal pain, and the cervical os was opened open and blood clot clots [minus 0.5 for GRAMMAR ERROR] were seemsseen [minus 1.5 for INCORRECT ENGLISH WORD] protruding from the os.

PHYSICAL EXAMINATION
GENERAL: : She is alert and oriented timesx 3 and , in [minus 0.5 for WRONG CONJUNCTION / PREPOSITION / ARTICLE] no acute distress.
VITAL SIGNS: Blood pressure 100/66, respirationrespirations 16, pulse 76, temperature 98.6.
PEVIC EXAMINATIONS: Reveals Pelvic examination reveals essentially healthy vagina with blood involved in the vault and [minus 1.5 for INCORRECT ENGLISH WORD] cervical os. The uterus is anteverted, 6 weeks sized and noble. weeks’ size, and mobile. [minus 1.5 for INCORRECT ENGLISH WORD/s] Adnexa are grossly normal. No palpable masses. Rectal examination was negative.
RECTAL EXAMINATIONS: Negative.
I sendsent [minus 0.5 for WRONG TENSE OF VERB] her forfor a sonogram to confirm an incomplete ABabortion, which was confirmed.

PLAN
We: Will [minus 1.5 for INCORRECT ENGLISH WORD] proceed with suctioned suction [minus 0.5 for MINOR ERROR] curettage under general anesthesia. She has been NPO n.p.o. [minus 0.5 for CAPITALIZATION ERROR] since 1:00, and pre operative blood work has been sent, including CBC, Pt, Ptt PT, PTT, [minus 0.5 for CAPITALIZATION ERROR] and urinalysis. She would will be [minus 0.5 for GRAMMAR ERROR] done under outpatient surgery.

line count = 25.49
negative pts. = 16.50 (64%)
ACCURACY = 36%